Headache Questionnaire

HEADACHE QUESTIONNAIRE
Chicago Dizziness and Hearing 645 N. Michigan, Suite 410 Chicago, Illinois, 60611 312-274-0197
NAME: AGE: Today's Date: Social Sec # HOME Phone: WORK Phone: PHARMACY Phone: Email address Fax
SEND REPORT(S) TO:
Please answer the following questions Please give necessary details for "yes" answers. We realize that this form is long, but when it is filled out carefully it allows us to devote more time to examining you.
Description of Present Illness

1a. My headaches started on:
1b. I get headaches about every: day week month three-months year (circle 1)
1c. My headaches last: seconds minutes hours days (circle 1)
1d. Describe the head pain you experience (circle one or several) throbbing tight grinding other: 1e: My headaches are located (mark location, one or several) pulsating squeezing vise-like pounding pressure hat-band constant sharp tender
Associations
2. Headache is accompanied by (circle) diarrhea dizziness drooping eye lid facial tenderness fever flushing on one side of the face light sensitivity loss of consciousness nausea or vomiting neck stiffness noise sensitivity numbness in face/arm/leg red, tearing eye runny nose/congestion swelling of ankles speech disturbance visual disturbances weakness in face/arm/leg
other:
3A. Is your head pain triggered by any of the following: (circle) other: Alcohol Barometric pressure or weather Bending over Blood Pressure Certain foods (such as cheese or Chocolate) Colds Coughing Depression, anxiety, nerves, or stress Exertion Fatigue Heat, hot showers Head movement Menstrual periods Missing a meal Monosodium glutamate (MSG) Odors Salt Sex Seasons Swallowing Sleep or Lack of sleep Time of day
3A. Is your head pain relieved by any of the following: (circle) Cold compresses Eating Heat Massage Medication (which ones ?) Moving around Relaxation Sleep Vomiting Other
HEADACHE QUESTIONNAIRE Life Style

4. Habits How many alcoholic drinks per day ? How many caffeinated drinks per day How many hours do you sleep per day ? Do you smoke cigarettes, cigars or pipes ? Are you currently involved in litigation with respect to any medical problems ? Are you usually highly stressed ? Do you usually eat 3 meals/day ? No Yes
No No No
Yes Yes Yes
5. Injuries (Circle, date)

head neck (for example whiplash) dental work preceding onset of headache ?
6. Exposures or Infections (Circle, date)

Carbon Monoxide (car or house) Venereal Disease or Syphilis ? Tuberculosis or Cysticercosis ?
HEADACHE QUESTIONNAIRE MEDICATIONS

7a. What are your current medications, include hormones, birth control pills, vitamins, etc. (Name and amount/day)?
7c. Have you ever taken any of the following medicines for headache : (circle)
Abilify Adipin Acetaminophen Advil Alleve AlkaSeltzer Amerge (triptan) Amitriptyline Anacin Anafranil Antihistamines Asendin Aspirin Axert (triptan) Axotal Aventyl Baclofen Bellergal Beta-blocker Blockadren Bufferin Cafergot Calan (verapamil) Cardene Cardizem Catapres Corguard Codeine Cymbalta Cyproheptadine Darvon/Darvocet Datril Dapro Desyril Dilantin Decongestants Demerol Depakote DHE Duradrin Duragesic Ecotrin Effexor Elavil (amitryptyline) Empirin Ergomar (ergot) Ergostat (ergot) Esgic Equigesic Excedrin Fentanyl patch Feverfew Fiorinal Fioricet Flexeril Gabapentin Ibuprofen Imitrex Inderal (propranolol) Indocin Indomethacin Isoptin Lamictal Lexapro Limbitrol Lithium Liorisal Lopressor Lortabs Lorcet Ludiomil Lyrica Magnesium Marplan Maxalt (triptan) Methadone Mexetil Micranin Midol Midrin Migranol Motrin Naprosyn Neurontin Nimodipine Norflex Norgesic Norpramin Nortriptyline Nubain Nuprin Oxygen Oxycontin Pamelor Panadol Parafon Forte Parnate Paxil Pertofrane Percocet Percodan Percogesic Periactin (cyproheptadine) ohenergan Phrenilin Procardia Propranolol (inderal) Prozac Reglan Relpax (triptan) Robaxin Serzone Sansert Sinequan Sinutab Skelaxin Soma Stadol Nasal Spray Sumatriptin (triptan) Surmontil Talwin Tenormin Thorazine Timonol Topamax Toprol Torecan Trexan Triavil Trilifon Trileptal Tylox Tylenol Tylenol #3 or #4 Vanquish Venlafaxine (Effexor) Verapamil (Calan) Verelan (verapamil) Viskin Vivactyl Vicodin Wellbutrin Wigraine Zomig Zonegran Zoloft Herbal products Petadolex
Past Medical History, Review of Systems

8. My health has been affected by (circle, date)
General Health Problems

Heart problems High cholesterol High or low blood pressure Diabetes Palpitations (abnormal or fast beating) of the heart
Treatment by a psychiatrist or counselor Depression or unusual amounts of stress Panic Attacks
Lyme disease Meningitis Tuberculosis (TB)
Eye Problems Pain

Pain in back of jaw (TMJ) Migraine or other headaches Low Back or Neck Pain Crossed eyes, lazy eye Poor vision in one eye (amblyopia)
Cancer What type 15 lb or more weight loss
Neurological Problems
Bladder problems Tremor or incoordination Loss of consciousness (faints or seizures) Pins and needles, numbness (where) Muscle weakness (where) Problems with sexual function Trouble speaking
Systemic Diseases AIDS
Metabolic
Kidney problems, Dialysis Liver problems Low sugar (hypoglycemia) Thyroid disorders
Arthritis Blood diseases, anemia Skin diseases Lupus Fevers or swollen glands Syphilis or venereal disease Mononucleosis (Epstein Barr)
Psychological Troubles
Surgery
HEADACHE QUESTIONNAIRE Family History

9. Are there any family members with (circle): Headaches just like mine Diabetes Stroke Heart disease or high blood pressure Migraine headaches Other diseases that run in the family (list) for malaria)
PREVIOUS STUDIES
11. Have you had any of these tests or procedures ? (circle, date if done, and please note result if known) OTHER SPECIALTY VISITS Eye Doctor Dentist Chiropracter
NEUROLOGICAL TESTS Carotid Doppler Lumbar puncture (spinal fluid examination) EEG (Brain Wave test for seizures) GENERAL MEDICAL TESTS Recent general medical checkup? Recent general blood tests (Glucose, blood count) Heart testing (EKG, Stress test, Holter Monitor) X-RAYS Cerebral Angiogram CT scan of the head MRI, MRA Sinus X-rays or CT Neck X-rays, CT or MRI Chest X-ray
THANK YOU !
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HEADACHE QUESTIONNAIRE

SEND REPORT(S) TO:

Description of Present Illness

1c. My headaches last: seconds minutes hours days (circle 1)

HEADACHE QUESTIONNAIRE Life Style

Yes Yes Yes

5. Injuries (Circle, date)

6. Exposures or Infections (Circle, date)

HEADACHE QUESTIONNAIRE MEDICATIONS

Past Medical History, Review of Systems

General Health Problems

Treatment by a psychiatrist or counselor Depression or unusual amounts of stress Panic Attacks

Lyme disease Meningitis Tuberculosis (TB)

Eye Problems Pain

Cancer What type 15 lb or more weight loss

Systemic Diseases AIDS

HEADACHE QUESTIONNAIRE Family History

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