Headache Questionnaire

Print, fill out, and bring to your appointment if you wish to speed things up.

Name:__________________________________________ Date:___/___/_____

Please circle the appropriate answer if YES please rate from 0-10

(0 = no problem/none – 10 = the worst/a lot) in the box. ie: Yes/No 8

How long have you been experiencing headaches?__________

How many headaches do you get per week? _____/Week

What time of day do they occur?__________

Do you wake up with a headache?. Yes/No

Where are the headaches located?__________

How long do they last?__________

Do they occur on weekends? Yes/No

Do the headaches occur while using your eyes? Yes/No

If yes, is this while you are using your eyes for computers, distance or near?

How do you get relief? Aspirin, Medication, Sleep, Massage, Stop the Activity or Other?

__________________________________________________________________

What are you doing immediately before the headaches begin?_____________________

__________________________________________________________________

Do you have a family history of headaches? Yes/No

Can you avoid the headaches? Yes/No

How?_______________________________________________________________

Are you currently experiencing:

Work Stress / Home Stress / School Stress / Health problems / Medication changes (please explain)

____________________________________________________________________

What best describes your headache:

Throbbing, dull, deep, shooting, non-throbbing, awakens you from sleep, slight, mild, moderate, severe, other.

Do you experience any of the following with your headache:

Nausea, vomiting, stiff neck, flashing lights, shimmering borders or zig-zag lines around your vision, tearing, nose or sinus stuffiness, sore jaw, vision loss, double vision, drowsiness, other.

Do you have allergies? Yes/No

Have you had any previous evaluations or care for your headaches? Yes/No