Please provide your referring or regular doctor s full name, address, phone number, and fax number. HEADACHE HISTORY
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- Georgina Russell
- 5 years ago
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1 PATIENT INFORMATION Patient Name (Last, First, Maiden) Date of Birth Age Social Security Number Please provide your referring or regular doctor s full name, address, phone number, and fax number. Referring Physician or Primary Care Doctor: Address: City, State Zip Phone: 1. Onset Of First Headache: Headaches started years ago. HEADACHE HISTORY I was: years old. 2. Precipitating Event (what provoked you first headache): None known Injury Menarche (first period) Pregnancy Other: 3. Location of Pain: Temples (temporal) Back of head (occipital) Side of head (parietal) Front of head (frontal) Around head (holocranial) Eye Ear Neck Jaw Other: 4. Sidedness: Right-sided Left-sided Both Sides Varies 5. Changes Sides: Between attacks During Attacks Both between and during 6. Pain Characteristics: Throbbing/Pulsing Achy Tight Dull Stabbing Pressure Burning Searing Shooting Other Severity: (How bad is the pain on a scale of 0 to 10: where 0 is no pain and 10 is the worst) Lowest and highest level of pain for this headache: Low to High Usual severity of this headache type: Worse with menses? Headache disability during or after an attack: Normal activity Severe decrease in function Slight decrease in function Moderate decrease in function Confined to bed
2 7. Duration: Lasts minutes hours days (with medication) How often does it recur within 24 hrs? % Lasts minutes hours days (without medication) How often does it recur within 24 hrs? % Headaches are continuous 8. Frequency: (the number of attacks) #/day #/week #/month # per year # of lifetime attacks continuous Are they increasing in frequency? Yes No (a) How many days in the last month did you experience headaches? (This includes all days of head or facial pain whether it be mild, moderate, or sever in intensity) days per month (b) Based on your answer to question (a), how many of these days are your headaches moderate to severe in intensity? (For example, you may experience 20 days of headache per month, of which only 10 are moderate to severe in intensity) days per month Are you ever HEADACHE FREE? Yes No 9. Premonitory Symptoms (you experience one or more of these symptoms before onset of headache): Heightened feeling of wellness Difficulty concentrating Increased appetite Hyperactive Sensitive to light Decreased appetite Extremely talkative Sensitive to sound/noise Feeling cold Depressed feeling Sensitive to odors Diarrhea Irritability Difficulty with speech Constipation Feeling sluggish Excessive yawning Extremely thirsty Drowsy Neck stiffness Increased urination Restless Food cravings Fluid retention Dizziness Weakness Other: 10. Headache Patterns Current Pattern: Sudden Rapid Gradual Varies Time of day: Are they more frequent: Morning Afternoon Evening Night Awakens from sleep Varies Weekends Weekdays Vacation Seasonal Spring Summer Fall Winter 11. Associated Symptoms: Nausea Increased urination Increased appetite Sensitive to: Sore/stiff neck Decreased appetite Light Ringing in the ears Eye-tearing [Rt Lt Both] Sounds Blurred vision Nose congested [Rt Lt Both] Odors Anxiety Eye-redness [Rt Lt Both] Diarrhea Irritability Drooping eyelid [Rt Lt Both] Constipation Concentration problems Change in pupil [Larger Smaller] Insomnia Memory problems Other: Vomiting Confusion Other:
3 12. Aura: Visual (Do you have these symptoms before your headache begins?) Blurry vision Loss of vision in one eye Tunnel vision Flashing lights Loss of vision on one side Double vision Zigzag lines Total blindness Other: Do the symptoms spread? Yes-spreads slowly No-begins all at once The visual symptoms start: before headache pain during headache pain both before and during The visual symptoms last a total of:. How long does the aura last before the head pain starts? How long does the aura and head pain last altogether? If you have more than one symptom, do they happen: One after the other or All at once? Do you have a visual aura without headache pain? Yes No 13. Aura: Sensory (Do you have these symptoms before your headache begins?) Numbness/tingling Light headedness Unable to speak [ Right Left Both] One-sided weakness Other: Dizziness/unsteadiness General weakness Other: Vertigo Speech difficulty Does the sensory aura spread? Yes-spreads slowly No-begins all at once The sensory aura starts: before headache pain during headache pain both before and during The sensory aura altogether lasts:. How long does the aura last before the onset of head pain? How long does the aura and head pain last, if both occur at the same time? If you have more than one symptom, do they happen: One after the other or All at once? Do you experience sensory aura without headache pain? Yes No 14. Provoking Factors: (things that bring on a headache) Food/beverage: Fasting Chocolate Caffeine Nitrates MSG Alcohol beverages Wine: [ Red White] Other: Physical exertion: Coughing Talking Chewing Exercise Sexual intercourse Hormonal: Menses: Before During After Pregnancy Menopause Stress: Work Home Family Spouse Other: Environmental: Allergies Weather changes Altitude Sunlight Other: Sleep: Lack of sleep Too much sleep Change in wake/sleep Other Triggers: 15. Activity that worsens headache: None Climbing steps Walking Exercise Other: 16. Relieving Factors: Lying down Dark quiet room Massage Hot compress Cold compress Pregnancy Keeping active/pacing Standing Other:
4 Please circle any medications that you have taken for your headache Advil (ibuprofen) Medrol Dose Pak Aleve Methadone Vicoprofen Amerge Methergine Vioxx Anaprox Medrin Vistaril Antivert Migralief Voltaren (diclofenac) Arthrotec Migranal Wigraine Aspirin Morphine Xanax (alprazolam) Axert Motrin (ibuprofen) Zanaflex Bellergal MS Contin Zofran Benadryl MSIR Zomig Cafergot Naprelan Zyprexa Celebrex Naprosyn Other Celexa Navane (thiothixene) Clinoril (sulindac) Nembutal Codeine Norflex Compazine Norgesic Davocet Nubain Daypro Orudis Decadron Oruvail Demerol Oxy IR/Oxycodone DHE OxyContin Dilaudid Parafon Forte Duragesic patch Percocet Excedrin Percodan Feldene Phenergan (promethazine) Feverfew Phrenilin Fioricet Prednisone (prednisolone) Fioricet with codeine Reglan (metoclopramide) Fiorinal Relafen (ketoprofen) Fiorinal with codeine Relpax Flexeril Robaxin Frova Skelaxin Haldol Soma Hydrocodone Stadol Imitrex tabs Talwin Imitrex nasal spray Thorazine (chlorpromazine) Imitrex injections Tigan Indocin (indomethacin) Toradol (ketorolac) Klonopin (clonazepam) Tylenol Lortab Valium (diazepam) Maxalt Vicodin
5 Previous Treatments and testing Primary care provider Neurologist Otolaryngologist (ENT) Dentist/dental Chiropractor Ophthalmologist Psychiatrist/psychologist Biofeedback/relaxation Physical therapy Massage Acupuncture/acupressure Herbal/homeopathic medicine Other: Previous Tests (Please give data and results) Head MRI MRA/MRV Cervical MRI Lumbar spine MRI Head CT EEG Lumbar puncture EKG EMG Sleep study Other:
6 Past Medical History 1. General Health: Excellent Good Fair Poor 2. Have you had any of the following medical problems? Diabetes Arthritis Ulcers/gastrointestinal problems Hypertension Cervical neck/spine problem Kidney/renal disease Heart Disease Skin problems Infectious disease Stroke Cancer Type: Seizures/epilepsy Type: Gynecological problems Head injury Hepatitis/liver disease Psychiatric Ear, nose, and throat proble Deep vein thrombosis Hospitalizations (See Below) Dental problems Thyroid disease Other: Asthma Pulmonary disease 3. Have you ever been hospitalized or had surgery? (List reason, date, hospital) Reason for Hospital Stay Date Hospital Medication List Please list ALL medications currently taken; include over the counter medications (such as Tylenol, advil, Excedrin, etc.), herbs, supplements, and vitamins. a. In Column A, please write each medication you use b. In Column B, please write the number of milligrams of the medication you take c. In Column C, write the number of times you take each medication per day (i.e. 1 pill 2 times/day) A B C Medication Name Dose in Milligrams # of Time Taken per Day Please list ALL allergies Medication Name Reaction
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Pinkston Psychology, LLC Ph. (318) 553-5099 paula@pinkstonpsychology.com Fx. (318) 553-5338 ADULT HISTORY FORM Date Completed this form Patient Spouse Parent Other Patient s Name Date of Birth Age Sex
Birthdate: / / Address: Age: Sex: M F. Telephone: H ( ) City State Zip W ( ) C ( )
Please complete this questionnaire in its entirety, even if you feel some questions may not apply to you. Our staff is available should you have any questions, or need assistance with the completion of
Computerized Dynamic Posturography (CDP) & Videonystagmography (VNG) Packet
Computerized Dynamic Posturography (CDP) & Videonystagmography (VNG) Packet Name: Audiologist: Nicole Smith, Au.D Trista Williams, Au.D DOB: Location: DOS: Balance Clinic Information At the DeFatta ENT
Florida Hospital Spine Center Patient Intake Form
Florida Hospital Spine Center Patient Intake Form Today s Date Last Name First Name Middle Street Address DOB (Address, City, State, Zip Code) First Contact # Please Circle: Home Cell Other Second Contact
PAIN QUESTIONNAIRE. Patient Name: Patient Date of Birth: Appointment Date:
Patient Name: Patient Date of Birth: Appointment Date: Please mark and/or notate the areas of your body which are affected by pain. RIGHT RIGHT LEFT LEFT RIGHT LEFT RIGHT RIGHT LEFT LEFT RIGHT LEFT For
HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
New Patient Questionnaire/Assessment
Welcome to the St. Joseph Mercy Pain Institute. Your answers to the following questions are important for your evaluation and care. Please read each question carefully and answer all 4 pages as completely
Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code
Carmina F. Angeles MD/PhD 74 B Centennial Loop, Suite 100 Eugene, OR Ph (541) Fax (541)
Carmina F. Angeles MD/PhD 74 B Centennial Loop, Suite 100 Eugene, OR 97401 Ph (541) 686.3791 Fax (541) 686.3795 DISCHARGE INSTRUCTIONS FOR ANTERIOR CERVICAL DISCECTOMY AND FUSION It is important to me
Pediatric Sleep History
Fax 423-431-2983 Pediatric Sleep History Patient/ Child s Name: Date of Birth: Parent Name: Last 4 of Social Security No: Gender: Male Female Height: Weight: Age: Race: Street Address: City: State: Zip:
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
SARAH VLACH, MD TYLER HEDIN, MD JUDY GOOCH, MD
Name: Height: Birthdate: Weight: Chief Complaint: What is the reason for your appointment? (please describe why you are here) Medications: Please list ALL medications with dosages you are currently taking,
~ ColumbiaDoctors Adult New Patient Intake Form Patient Information
~ ColumbiaDoctors Adult New Patient Intake Form Patient Information Last Name: First Name: DOB: Gender: Home Phone: Mobile Phone: ---------- Preferred Phone: Home or Mobile (circle one) Email: -----------