New Patient Consultation Mia Minen, MD, MPH Patient Name: Sex: Age: Date: Date of Birth: Referring Physician: Which hand do you write with: Right / Left / Ambidextrous Height: Weight: Please briefly describe the reason for your visit today: -How old were you when you first began to suffer from headaches? -Is you headache on one side of the head or both sides? One Both -On average, on a scale of 1-10 with 10 being the worst pain you can imagine, what is the range of pain intensity? -Please circle the pain quality: throbbing/pulsating, dull, stabbing, tingling,numb, other: -Please circle which of the following you have with your headaches: Nausea Vomiting Light sensitivity Sound Sensitivity -Have you ever been told that you have aura (e.g. loss of vision, flashing lights, numbness or weakness before or during your headaches? Yes No Please explain: -Untreated, for how long does your headache last? -How many days a month do you have a headache? -Can you do your regular routine or exercise when you have a headache? Yes No -History of head injury? No Yes-Please explain: -History of Central Nervous System Infection e.g. meningitis? No Yes
Family History of Headache? No Yes-Please state headache type and which family members: -On average, how many hours of sleep do you get a night? -Do you snore? No Yes If yes, have you ever had a sleep study? No Yes -Do you grind your teeth or have popping/clicking of your jaw (TMJ)? No Yes: Please explain: -Do you have sinus or allergy problems? No Yes -Do you suffer from any of the following? Anxiety Depression Obsessive Compulsive Disorder ADHD Learning disability Bipolar d/o PTSD Schizophrenia Other: Please list the medications you are currently taking, as well as the dose: Prior headache Medications: PLEASE LIST ALL DOSES AND LENGTH OF TIME IT WAS TAKEN Abortive Medications NSAIDS Ibuprofen e.g. Motrin Indomethacin e.g. Indocin Ketoprofen e.g. Orudis Ketorlac e.g. Toradol Naproxen e.g. Naprosyn Diclofenac e.g. Voltaren, Cambia Etodolac e.g. Lodine
Other: Triptans Almotriptan (Axert) Frovatriptan (Frova) Naratriptan (Amerge) Rizatriptan (Maxalt) Sumatriptan (Imitrex) Zolmitriptan (Zomig) Eletriptan (Relpax) Other: Anti-nausea Meclizine e.g. antivert Metoclopramide e.g. Reglan Prochlorperazine e.g. Compazine Promethazine e.g. Phenergan Ondansetron e.g. Zofran Narcotics/Opioids Hydrocodone e.g. vicodin Oxycodone or Oxycontin e.g. Percocet, Codeine e.g. fioricet with codeine Butorphanol e.g. stadol Fentanyl e.g. duragesic Meperidine e.g. Demerol Tramadol e.g. ultram Buprenorphine/naloxone e.g. suboxone Benzodiazepines Alprazolam e.g. Xanax Buspirone e.g. buspar Clonazepam e.g. klonopin Lorazepam e.g. Ativan Zolpidem e.g. ambien Diazepam e.g. valium Other: Preventive Medications: Beta blockers Propranolol Atenolol Nadolol Timolol Tricyclics Amitriptyline Nortiptyline Imipramine Desipramine
AEDs Topiramate Zonisamide Valproic Acid Gabapentin Carbamazepine Ozcarbazepine Levetiracetam Pregabalin ACE Inhibitors Captopril Enalapril Lisinopril Candesartan Valsartan Supplements Co-Q10 Vitamin B2/riboflavin Feverfew Magnesium Butterburr e.g. petadolex Migralieve Melatonn Ginger Other: Hormones: Muscle Relaxants Tizanidine e.g. zanaflex Cyclobenzaprine e.g. flexeril Baclofen e.g. Lioresal Carisoprodol e.g. Soma Orphenadrine e.g. Norflex Other: Botox: Number of times injected: Diuretic Acetazoladmide e.g. diamox Steroids Prednisone e.g. deltasone Dexamethasone e.g. decardon, Medrol Calcium Channel Blockers Amlodipine Diltiazem Nifedipine
Verapamil SSRIS/SNRIs Duloxteine Venlafaxine Sertraline Fluoxetine Citalopram Antipsychotics Quetiapine e.g. Seroquel Risperidone e.g. Risperdal Stimulant/Anti-Mania Dextroamphetamine e.g. Dexedrine Lithium Methylphenidate e.g. Ritalin Other: Non-Headache Neurologic History: Please check off if you have any of the following: Tourette Syndrome Parkinson s Disease Essential Tremor Multiple Sclerosis Epilepsy Dystonia Please list any current or past medical conditions (ex: cancer, heart disease, high blood pressure, high cholesterol, diabetes, ulcers, thyroid disease) Do you have a pacemaker? Yes Do you wear hearing aids? Yes No No Please list any surgical procedures you have had: Please list your allergies to medications, food, dye: Are you single, married, other: Current occupation: Former occupation: Alcohol Use: y / n Drinks per day/week:
Cigarette Use: y / n Cigarettes per day: Please list any significant medical conditions that have occurred in your family (ex: heart disease, high blood pressure/cholesterol, and in particular: stroke, parkinson s disease, seizures, brain tumors, dementia, migraines, multiple sclerosis, or other neurologic conditions) Mother: Father: Siblings: Children: Others: Please circle any of the following symptoms that you currently have: General: fever / chills / sweats / excessive fatigue / malaise / weight loss/change in appetite Eye: blurred vision / double vision / visual loss / eye pain / light sensitivity ENT: ear pain / ringing in ears / decreased hearing / sore throat / trouble swallowing Cardiovascular: chest pain / palpitations / fainting / shortness of breath / circulatory problems in arms or legs Respiratory: coughing / wheezing / bloody sputum GI: nausea / vomiting / diarrhea / constipation / abdominal pain GU/GYN: urinary incontinence / urinary retention / kidney stones / prostate problems / menstrual irregularities Musculoskeletal: spine pain / joint pain / muscle cramps / Skin: rash / itching / dryness Mood: depression / anxiety / difficulty sleeping / hallucinations Glandular: cold or heat intolerance / excessive thirst or drinking Hematological: abnormal bruising / bleeding / enlarged lymph nodes
Sleep Assessment For each question, please CIRCLE the best answer. Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s). Insomnia None Mild Moderate Severe Very Severe Problem 1. Difficulty falling asleep 2. Difficulty staying asleep 3. Problems waking up too early 4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern? Very Satisfied Satisfied Moderately Dissatisfied Very Dissatisfied Satisfied Insomnia impact 5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life? 6. How WORRIED/ DISTRESSED are you about your current sleep problem? 7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY? Not at all A little Somewhat Much Very much 8. How long have you had difficulties with sleep? Less than 3 months. More than 3 months. Years. 9. What do you think is the cause of your difficulty falling asleep or staying asleep? Headache Pain Running thoughts/anxiety Noise Heat Other 10. During the past month, what time have you usually gone to bed at night? If your bedtime varies from day to day, please provide the time range. BED TIME 11. During the past month, how long (in minutes) has it usually taken you to fall asleep each night? NUMBER OF MINUTES 12. During the past month, what time have you usually gotten up in the morning? GETTING UP TIME 13. During the past month, how many hours of actual sleep did you get at night? (This may be different than the number of hours you spent in bed.) HOURS OF SLEEP PER NIGHT 14. Do you take naps during the day? every day sometimes never
PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use to indicate your answer) Not at all Several days More than half the days Nearly every day 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. 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 9. Thoughts that you would be better off dead or of hurting yourself in some way FOR OFFICE CODING 0 + + + =Total Score: 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 Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.
GAD-7 Over the last 2 weeks, how often have you been bothered by the following problems? (Use to indicate your answer) Not at all Several days More than half the days Nearly every day 1. Feeling nervous, anxious or on edge 2. Not being able to stop or control worrying 3. Worrying too much about different things 4. Trouble relaxing 5. Being so restless that it is hard to sit still 6. Becoming easily annoyed or irritable 7. Feeling afraid as if something awful might happen (For office coding: Total Score T = + + ) Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.