SOME PEOPLE HAVE MORE THAN ONE TYPE OF HEADACHE -

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1 Dr. Brenda C. Slovin Dr. Erik S. Slovin (Fax) Pain relief without drugs or surgery! Rainbow Plaza 205 Main Avenue Norwalk, CT HEADACHE SPECIFIC QUESTIONS - What is your biggest concern about your headaches: Do you have sick / severe headaches: YES NO Date sick / severe headache started: How many sick / severe headaches have you had in your life: >100 Frequency of sick / severe headaches (per month and per year): AGE MONTH YEAR DESCRIBE As a child less than 12 years As an adolescent years As a young adult years As an adult over 30 years Were you adopted: YES NO Does anyone in the family have headaches (migraine, sick, sinus, tension, cluster, other): RELATION YES NO DESCRIBE RELATION YES NO DESCRIBE Mother Father M. Gma P. Gma M. Gpa P. Gpa M. Aunts P. Aunts M. Uncles P. Uncles Sisters Brothers Daughters Sons Were you ever carsick as a child: YES SOCIAL HISTORY - NO Do you use any of the following: Caffeine (coffee, tea, soda): YES NO If yes, number of ounces per day: 0 OZ Tobacco: YES NO If yes, number of cigarettes / amount of chew per day: cigarettes / chew / other Alcohol / Beer / Wine / Liquor: YES NO If yes, number of drinks per week: drinks Recreational / Street Drugs: YES NO If yes, please explain: What is your marital status: single married separated divorced widow / widower What is your current occupation: Work hours per week: HRS What is your level of education: high school some college bachelors degree graduate degree

2 NEW NEW PATIENT PATIENT QUESTIONNAIRE QUESTIONNAIRE - Page 2 SOME PEOPLE HAVE MORE THAN ONE TYPE OF HEADACHE - How many days have you had a headache in the last: month: days 3 months: days 6 months: days Visits to the ER in the last 12 months: visits Days missed at work or school in the last month: days On a scale of 1-10, on average, how painful are your headaches: (1= pain free, 10 = pain is unbearable) Headache frequency, type, location, and symptoms: number per year number per month severity (1-10) length (hours) -TYPE OF PAINthrob stab ache sharp pulsating pressure in head jabs & jolts - LOCATION OF PAIN - right left temples behind eye all over back of neck - ASSOCIATED SYMPTONS - nausea vomiting photosensitivity (light) phonosensitivity (sound) smell sensitivity aggravated by activity/movement worse in: (morning, afternoon, or night) effect on life: (no interference, some interference, no activity, bedridden, or emergency room) MOST SEVERE HEADACHE DAILY HEADACHE OTHER HEADACHE TYPE FACE PAIN

3 NEW NEW PATIENT PATIENT QUESTIONNAIRE QUESTIONNAIRE - Page 3 OTHER SYMPTOMS ASSOCIATED WITH YOUR HEADACHES - Aura Symptoms Vision: blur blindness zig zag lines spots bright flashes Sensory: numbness tingling (Location: Duration: ) Brainstem: vertigo / dizziness Speech: difficulty finding words / speech arrest Motor: weakness in one side of face or body Duration of aura: minutes Onset of headache after aura: minutes Aura before every headache: YES NO Headache after every aura: YES NO Aura without headache: YES NO Other symptoms: nasal stuffing / running flushing eye lid drooping / swelling scalp tenderness skin sensitivity neck tenderness weakness odor sensitivity sweating pupil dilated OTHER HEADACHE CHARACTERISTICS - Does this headache wake you from your sleep: YES NO Is your headache worse: Upright: YES NO Lying down: YES NO Have you ever had a serious head injury with loss of consciousness: YES NO Date: Have you had any history of mild head injury (sports, whiplash assault, etc): YES NO Date: Have you had a recent viral illness prior to headache onset: YES NO Date / Explain: TRIGGERS - Diet: alcohol meat msg caffeine Environment: light sound smell weather travel altitude temperature Physical: exercise position sleep pattern sexual activity Emotional: anger anxiety stress depression fatigue Hormones: menstrual cycle ovulation pregnancy menopause OTHER SYMPTONS / CHARACTERISTICS / TRIGGERS -

4 NEW NEW PATIENT PATIENT QUESTIONNAIRE QUESTIONNAIRE - Page 4 HEADACHE DISABILITY-MIDAS QUESTIONNAIRE - 1. How many days in the last 3 months did you miss work / school because of your headaches: days (If you do not attend work or school write 0 ) 2. How many days in the last 3 months was your productivity at work or school reduced by half or more: days (Do not include days you counted in Question #1) 3. How many days in the last 3 months did you not do household work because of your headaches: days 4. How many days in the last 3 months was your productivity in the household work reduced by half or more: days (Do not include days from Question #3) 5. How many days in the last 3 months did you miss family social, or leisure activities because of headaches: days TOTAL: 0 days A. How many days in the last 3 months did you have a headache: days (If a headache lasted more than 1 day, count each day) B. On a scale of 0 10, on average how painful were these headaches: (Where 0 = no pain at all, and 10 = pain as bad as it can be) PREVIOUS HEADACHE WORKUP - Innovative Medical Research 1997 CT scan / x-rays MRI blood work eeg lumbar puncture sleep study general practice / internal medicine evaluation neurologist chiropractor dentist psychologist / psychiatrist pain clinic physical therapist ophthalmologist / last eye exam DATE PLACE PROCEDURES FOR HEADACHE - botox nerve blocks acupuncture DATE RESPONSE

5 NEW NEW PATIENT PATIENT QUESTIONNAIRE QUESTIONNAIRE - Page 5 CURRENT MEDICATIONS AND ALLERGIES - Are you taking any prescriptions and/or non prescriptive medications (if yes, please list below): YES NO MEDICATION DOSE FREQUENCY OVER-THE-COUNTER (including herbals & supplements) DOSE FREQUENCY Have you had any allergic reactions to any medications (if yes, please list below): YES NO NAME OF MEDICATION PROBLEM

6 NEW NEW PATIENT PATIENT QUESTIONNAIRE QUESTIONNAIRE - Page 6 PREVIOUS SURGERIES, ILLNESSES, & ACCIDENTS - List and describe any surgeries that you have had: DATE OF SURGERY DESCRIPTION OF SURGERY List major illnesses that you have had: DATE OF ILLNESS DESCRIPTION OF ILLNESS List any serious accidents or injuries that you have had: DATE OF ACCIDENT DESCRIPTION OF ACCIDENT List any prior history of depression or psychological difficulty: DATE EXPLAIN (hospitalization, outpatient treatment, etc) DIET & EXERCISE - Dietary restrictions / preferences: Number of servings of fruits and vegetables per day: servings Do you exercise: YES NO Type of exercise: Number of days of exercise per week: days Are you overweight: YES NO If yes, by how many pounds: LBS

7 NEW NEW PATIENT PATIENT QUESTIONNAIRE QUESTIONNAIRE - Page 78 REVIEW OF SYSTEMS (If experienced within the previous 6 months, please check if yes ) - General / Constitutional: weight loss (Specify: lbs) weight gain (Specify: lbs) fatigue poor state of health (Explain): Skin / Breast: rash itching injection site issues breast lumps tenderness swelling nipple discharge changes in hair growth or loss, nail changes (Explain): Eyes / Ears / Nose / Mouth / Throat: vertigo / dizziness lightheadedness vision changes double vision tearing blind spots nose bleeding frequent colds dental difficulties bleeding gums neck stiffness neck pain masses in thyroid Cardiovascular: chest pain palpitations / irregular heartbeat syncope / fainting edema / swelling poor circulation / discoloration of hands & feet Respiratory: shortness of breath wheezing cough fever / night sweats Gastrointestinal: change in appetite problems swallowing indigestion / heartburn nausea / vomiting constipation diarrhea abdominal pain Genitourinary: urgency frequency painful urination frequency at night number of times with kidney stones infections change in sexual drive Females: age of onset of menses number of pregnancies number of deliveries number of miscarriages / abortions number of living children Musculoskeletal: muscle / joint pain swelling / redness of muscles or joints muscular weakness Neurologic / Psychiatric: numbness weakness memory / speech difficulty motor / muscular coordination problems emotional problems anxiety depression unusual perceptions / hallucinations Allergic / Immunologic / Lymphatic / Endocrine: food reactions insects environmental exposures anemia bleeding tendency previous transfusions & reactions local or general lymph node enlargement or tenderness (Location: ) frequent thirst / drinking / urination intolerance to heat or cold seasonal allergies (Explain): Other:

8 NEW NEW PATIENT PATIENT QUESTIONNAIRE QUESTIONNAIRE - Page 89 DAILY MEDICATIONS TAKEN IN THE PAST TO HELP PREVENT HEADACHE - DRUG DOSE HOW LONG EFFECT ON HEADACHE - NONSTEROIDAL ANTIINFLAMMATORIES - ibuprofen (Motrin, Advil) naproxen (Naprosyn) celecoxib (Celebrex) piroxicam (Feldene) diclofenac (Voltaren) indomethacin (Indocin) meloxicam (Mobic) nabumetone (Relafen) - CARDIAC MEDICATIONS - timolol (Blocadren) nadolol (Corgard) propranolol (Inderal) metoprolol (Lopressor,Toprol) atenolol (Tenormin) verapamil (Calan, Isoptin, Verelan) amlodipine (Norvasc) nifedipine (Procardia) diltiazem (cardizem) clonidine (Catapress) - PSYCHOTROPIC MEDICATIONS - amitriptyline (Elavil) nortriptyline (Pamelor) imipramine (Tofranil) doxepin (Sinequan) desipramine (Norpramin) protriptyline (Vivactil) fluoxetine (Prozac) sertraline (Zoloft) paroxetine (Paxil) citalopram (Celexa) escitaloproam (Lexapro) venlafaxine (Effexor) desvenlafaxine (Pristiq) duloxetine (Cymbalta) mirtazapine (Remeron) fluvoxamine (Luvox)

9 NEW NEW PATIENT PATIENT QUESTIONNAIRE QUESTIONNAIRE - Page DAILY MEDICATIONS TAKEN IN THE PAST TO HELP PREVENT HEADACHE (continued) - DRUG DOSE HOW LONG EFFECT ON HEADACHE trazodone (Desyrel) nefazodone (Serzone) bupropion (Wellbutrin) phenalzine (Nardil) tranylcypromine (Parnate) aripiprazole (Abilify) olanzapine (Zyprexa) quetiapine (Seroquel) risperidone (Risperdal) ziprasodone (Geodon) - ANTISEIZURE MEDICATIONS - valproic acid (Depakote) gabapentin (Neurontin) pregabalin (Lyrica) phenytoin (Dilantin) carbamazepine (Tegretol, Carbatrol) oxcarbazepine (Trileptal) topiramate (Topamax) lamotrigine (Lamictal) zonisamide (Zonegran) tiagabine (Gabatril) levetiracetam (Keppra) - MUSCLE RELAXANTS - carisoprodal (Soma) cyclobenzaprine (Flexeril) methocarbamol (Robaxin) tizanidine (Zanaflex) baclofen (Lioresal) orphenadrine (Norflex) metaxalone (Skelaxin) - ANTIANXIETY AGENTS - diazepam (Valium) clonazepam (Klonopin) alprazolam (Xanax) lorazepam (Ativan)

10 NEW NEW PATIENT PATIENT QUESTIONNAIRE QUESTIONNAIRE - Page DAILY MEDICATIONS TAKEN IN THE PAST TO HELP PREVENT HEADACHE (continued) - DRUG DOSE HOW LONG EFFECT ON HEADACHE - PAIN MEDICATIONS - hydrocodone / apap (Lortab, Vicodin) acetaminophen with codiene (Tylenol #3) extended release oxycodone (Oxycontin) extended release morphine (MS Contin, Kadian, Oramorph) fentanyl patch (Duragesic) methadone tramadol (Ultram) tapentadol (Nucyncta) oxymorphone (Opana) - SLEEP MEDICATIONS - zolpidem (Ambien) zaleplon (Sonata) eszopiclone (Lunesta) ramelteon (Rozerem) chloral hydrate (Somnote) melatonin - OTHER - methysergide (Sansert) cyproheptadine (Periactin) memantine (Namenda) What medications have worked best for you: What medications have worked best for a family member with headache: MEDICATIONS USED TO TREAT HEADACHE ACUTELY (as needed) - DRUG DOSE EFFECTIVE NOT EFFECTIVE isometheptene / dichloralphenazone/apap (Midrin) ergotamine (Cafergot, Wigraine) butalbital / apap / caffeine (Fioricet) with or without codiene butalbital / asa / caffeine (Fiorinal) with or without codiene apap / asa / caffeine (Excedrin) NUMBER OF DAYS USED PER WEEK

11 NEW NEW PATIENT PATIENT QUESTIONNAIRE QUESTIONNAIRE - Page MEDICATIONS USED TO TREAT HEADACHE ACUTELY (continued) - DRUG DOSE EFFECTIVE NOT EFFECTIVE COMMENTS apap / codiene (Tylenol #3) hydrocodone / apap (Lortab, Vicodin, Norco) oxycodone (Percocet, Roxicet) meperidine (Demerol) morphine hydromorphone (Dilaudid) tramadol (Ultram) ibuprofen (Motrin, Advil) naproxen (Aleve, Naprosyn) celecoxib (Celebrex) ketorolac (Toradol) tablet ketorolac (Toradol) injection dihydroergotamine injection dihydroergotamine nasal spray (Migranal) dihydroergotamine inhaler (Levadex) sumatriptan SQ injection (Imitrex, Sumavel) sumatriptan nasal spray (Imitrex) sumatriptan tablets (Imitrex) zolmitriptan nasal spray (Zomig) zolmitriptan (Zomig) ZMT or tab rizatriptan (Maxalt) MLT or tab almotriptan (Axert) frovatriptan (Frova) naratriptan (Amerge) eletriptan (Relpax) sumatriptan + naproxen (Treximet) lidocaine nose drops oxygen butorphanol nasal spray (Stadol) butorphanol injection (Stadol) steroids (Prednisone, Medrol Dose Pack)

12 NEW NEW PATIENT PATIENT QUESTIONNAIRE QUESTIONNAIRE - Page MEDICATIONS USED TO TREAT NAUSEA AND/OR VOMITING - DRUG DOSE EFFECTIVE NOT EFFECTIVE COMMENTS promethazine injection (Phenergan) promethazine tablets (Phenergan) promethazine suppositories (Phenergan) prochlorperazine injection (Compazine) prochlorperazine tablets (Compazine) prochlorperazine suppositories (Compazine) trimethobenzamide capsules (Tigan) trimethobenzamide suppositories (Tigan) metoclopramide (Reglan) hydroxyzine (Vistaril) ondansetron tablets (Zofran) ondansetron injection (Zofran) What medications have worked best for you: SUPPLEMENTS OR HERBAL PRUDCES USED FOR HEADACHE - PRODUCT DOSE EFFECTIVE NOT EFFECTIVE COMMENTS butterbur (Petadolex) feverfew riboflavin (Vitamin B2) magnesium coenzyme Q10 fish oil 5-hydroxytriptophan (5-HTP) St. John s Wort ginger migrelief

13 NEW PATIENT QUESTIONNAIRE - Page 13 PHQ-9 TEST (Use a check mark to indicate your answer) - Over the last 2 weeks, how often have you been bothered by the following problems? NOT AT ALL SEVERAL DAYS MORE THAN HALF THE DAYS NEARLY EVERY DAY Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you are a failure or have let yourself or your family down. Trouble concentrating on things, such as reading the newspaper or watching television. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual. Thoughts that you would be better off dead or of hurting yourself in some way (FOR OFFICE CODING: = Total Score 0 ) If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people: not difficult at all somewhat difficult very difficult extremely difficult Over the last 2 weeks, how often have you been bothered by the following problems? NOT AT ALL SEVERAL DAYS MORE THAN HALF THE DAYS NEARLY EVERY DAY Feeling nervous, anxious or on edge Not being able to stop or control worrying Worrying too much about different things Trouble relaxing Being so restless that it is hard to sit still Becoming easily annoyed or irritable Feeling afraid as if something awful might happen. Do you have trouble falling asleep? When did you first have trouble sleeping (months, years) (FOR OFFICE CODING: Total Score T 0 = + + )

14 NEW PATIENT QUESTIONNAIRE - Page 14 Liver Function Have you ever had elevated or high liver enzymes on laboratory blood work? Yes No Not Sure Do you have any funny reactions if you drink alcohol (little goes a long way, can't drink red wine, etc.)? If so please describe: Do you have any problems eating raw onions? Yes No The day after eating asparagus do you get a very strong odor when urinating (the next day?) Do you have hepatitis? Yes No Do you have a fatty liver? Yes No Do you have funny reactions to medications? Yes No Do strong odors (gasoline, smoke, cleaning supplies, perfume, etc.) bother you? Yes No Adrenal Function If you skip a meal do you feel bad (have headaches, become irritable, get jittery, tired, etc.) Yes No Do you have low blood pressure? Yes No Don't Know Do you crave salty foods? Yes No Does increased stress or stressful situations make your symptoms worse? Yes No How's your energy level? Scale of 1-5, with 5 being the best. How is your concentration and memory on a scale of 1-5, with 5 being best? How do you feel in the morning? Refreshed Hung over Exhausted Nauseated Achy All Over Are you hungry in the morning? Yes No End of Questionnaire - Thank you for your patience.

15 Migraine Diary Dr. Brenda Slovin The Headache Doctor The key to successful migraine treatment is YOU! The more involved you become in your treatment, the more likely you are to get relief from your migraine pain. The Migraine Diary is your most important tool. It helps you and your doctor track your migraines and how well your treatment is working. It will also help you identify migraine triggers that may be causing your migraines. Record your information as accurately and completely as you can. Then bring your Migraine Diary to your next doctor visit. How to Use the Migraine Diary The following instructions will explain how to complete each diary section. Migraine severity In this section, each day is broken down into morning, afternoon, and evening. On the days you have migraine pain, write a number in the appropriate box from 1 to 3 that describes your pain: 1 =mild; 2 =moderate; 3 =severe. Triggers There are many things that can cause (trigger) a migraine. The key on the next 2 pages assigns a number to each trigger. For example, chocolate is No. 6 and strong light is No. 23. Record the numbers of the triggers you have been exposed to on the day of your migraine. For women only: menstrual period Some women tend to get migraines around the time of their period. Place an X on the days you have your period. Medicines Write the names of any medicines, including over-the-counter and prescription, that you take to relieve your migraine pain including the dose. Below each medicine, use numbers 0 to 3 to indicate the overall level of relief you got from the medicine. For example, 0 =no relief; 1 =slight relief; 2 =moderate relief; and 3 =complete relief. Adapted from the New England Center for Headache: Headache Calendar

16 Migraine Triggers Dr. Brenda Slovin The Headache Doctor Use this key to complete the trigger section of the migraine diary Hormones 1. Menses (period) 2. Ovulation 3. Hormone replacement therapy 4. Oral contraceptives Diet 5. Alcohol 6. Chocolate 7. Aged cheeses 8. Monosodium glutamate (MSG) 9. Artificial sweeteners 10. Caffeine 11. Nuts 12. Nitrates and Nitrites (found in hot dogs, bologna, and other processed meats) 13. Citrus fruits 14. Other Changes 15. Weather 16. Seasons 17. Travel (crossing a time zone) 18. Altitude 19. Schedule change 20. Sleeping patterns (erratic or changes in normal patterns) 21. Diet 22. Skipping meals Sensory stimuli 23. Strong light 24. Flickering light 25. Odors Stress 26. Let-down periods (vacations, weekends, after a major event) 27. Times of intense activity 28. Loss (death, separation, divorce) 29. Relationship difficulties 30. Job stress, loss, or change 31. Crisis 32. Other

17 Migraine Diary Dr. Brenda Slovin The Headache Doctor MIGRAINE SEVERITY Day of Month The diary is numbered 1 31 for each day of the month. On the days you have migraine pain, record in the box the number that describes your migraine pain: 1=mild; 2=moderate; 3=severe Morning Afternoon Evening/Night Day of Month TRIGGERS MENSTRUAL PERIOD Triggers Each trigger has been assigned a number. Record the numbers of the triggers you may have been exposed to on the day of your migraine. Menstrual Period Place an X on the days you have your period. MEDICINES TAKEN (Record all medicines, including over-the-counter and prescription, used to treat migraine pain and related symptoms) On the days you take medicines to relieve your migraine pain, write the names of the medicines and the doses in the appropriate box. Place a check (ü) for each dose you take. Also, record in the appropriate box a number from 0 to 3 that describes the amount of overall relief you got from that medicine: 0=no relief; 1=slight relief; 2=moderate relief; 3=complete relief. Day of Month Medicine: Medicine: Medicine: Medicine: Medicine: Dose: Overall Relief Dose: Overall Relief Dose: Overall Relief Dose: Overall Relief Dose: Overall Relief