The patient is seen in follow up for

HEADACHE QUESTIONNAIRE
Patient name: ______________________________ DOB:_____________ Date: _________________ When did your headaches first occur? ______________________________________________ Description of headache: Location of headache? ______________________________________________________________ Any warning symptoms? ______________________________________________________________ Are you taking any over-the-counter medications for your headache, if so which ones and how many pills per day, week, or month? Do you have any of the following symptoms with her headache? (circle) Nausea Average number of headaches per month: ______ Typical duration of headaches: ___________________________________________________________ How long does it take for the headache to become severe? _____________________________________ Are there any triggers for the headache (foods, stress, menstruation)? _____________________________ Have you tried any of the following medications, and please describe the response. Have you tried any of the following a preventative medications for migraine, and please describe the response, dosage if known, and side effects? Amitriptyline/Elavil Propranolol/Inderal Verapamil/Calan Depakote Topamax Zonegran Neurontin Lyrica Prozac Paxil Welbutrin Other Have you had any MRIs, CT's? What facility? Name_______________________________ page 2 of 3 Date____________
Past Medical History: (Please check if applicable)
___ Gastrointestinal ___ Gynecological Problems Other: _____________________________________________________________________________ ___________________________________________________________________________________ Surgical History: ______________________________________________________________________
_____________________________________________________________________________________ Cigarettes _____ # cig/day x _____ # years Other tobacco usage: ______________________ Current frequency: _______________________ Recreational Drugs: _________________________________ Women Only:
Date of last period (1st day) __________ Menopausal symptoms? _______________________ Menstrual pain? _______________________________________ complaints? __________________________________________________________________ History of Pregnancies: _____________________________________________________________________ Family History:
Other: ______________________________________________________________________________ Allergies: _____________________________________________________________________________
______________________________________________________________________________________ Current Medications:
Medication Dosage Reason
Name_______________________________ page 3 of 3 Date____________ Review of Current/Recent Symptoms: (check all that are applicable)
___ Vision changes ___ Double vision ___ Glaucoma Other:__________________________________________________________________ ________________________________________________________________________ Other Comments: ________________________________________________________________________ ______________________________________________________________________________________ _________________________________________

Source: http://arundelneurology.com/uploads/Headache_questionnaire.pdf