HEADACHE HISTORY & PROFILE
Name:
Date of Birth:
Date:
How often does the headache occur?
x/Day
x/Week
x/Month
x/Year
Constant
How old were you when any headache started?
How long does it usually last?
Minutes
Hours
Days
Constant
Is the headache getting
worse
better
fluctuating
no change
Do your headaches interfere or prevent normal activities - work etc.?
No
Yes
How long ago did the current headaches start?
Weeks
Months
Years
Describe the degree of pain (check one):
1(slight)
2
3
4
5
6
7
8
9
10(worst)
How would you describe the pain?
Throbbing/pulsating
Pressing/squeezing
Stabbing
Sharp
Dull/nagging
Other
Does the headache awaken you from sleep?
Yes
No
On what part of the head do the headaches start?
(R) Side
Both sides
Forehead
Back
Face
Behind/around eyes
(L) Side
Either side
Temples
On top
Neck
Other
After the headache starts - Does it usually?
Stay in one place
Move around Please explain:
Are any of the following associated with the headache? Please mark
B
efore
D
uring
A
fter the headache occurs
B D A
Spots before eyes
Blindness (
R
L)
Blurring (
R
L)
Double vision
Can see only half of objects
Eyelid droop (
R
L)
Tearing (
R
L)
Eye redness (
R
L)
Eyes puffy (
R
L)
Light sensitivity
Noise sensitivity
Odors sensitivity
Nose blocked/discharge (
R
L)
----------------------------
Difficulty talking (finding words)
Difficulty understanding
Numbness around lips
Slurred speech
Fainting (feel like or have fainted)
Dizzy (lightheaded/ unsteady/ spinning)
B D A
Nausea
Vomiting
Loss of appetite
Hunger
Cramps
Diarrhea
Hands and/or Feet -
Cold
Pale
Sweaty
Mottled
Neck -
Stiff
Tender
B D A
Difficulty concentrating
Depression
Fatigue
Anxiety
Irritability
----------------------------
Face - Scalp -
Pale
Redness
Sweating
Puffy
Tender
Decreased jaw opening
Pain on chewing
B D A
Weakness (
W
)
Numbness (
N
) Both (
B
)
W N B
Face (
R
L)
Arms (
R
L)
Arm & Leg (
R
L)
Legs (
R
L)
Indicate if any of the following factors have brought on (trigger) your headache:
Sleep - too much - too little
Emotional stress
during
after
Depression - anxiety
Physical activity
Erect position
Bending over
Straining - coughing
Sexual activity
Change in weather
Seasons
------------------------------------------------
Missed meal
Alcohol
MSG
Processed meats
Chocolate
Citrus fruits
Cheeses
Other foods
------------------------------------------------
Menstrual periods
Pregnancy
Menopause
Contraceptives
Medications
Do any blood relatives have severe headaches?
No
Yes
If Yes, Who and diagnosis?
Which of the following makes the headache better?
Rest
Compresses
Activity
Scalp or temple pressure
Darkness
Pregnancy
Quiet
Menopause
Social History:
Cigarettes
/day
years
Are you or have you been
Depressed
Anxious
Previous professional treatment of headache?
No
Yes
If Yes, Who and When?
Previous x-ray or other investigations of headache?
No
Yes
If Yes, Describe:
Previous medications for headache?
No
Yes
If Yes, Name/Dosage:
ADDITIONAL NOTES: