2335 E. Kashian Lane, Suite 301, Fresno, CA 93701 559.264.9100 // 559.264.9199 fax

Headache Questionnaire

Patient Name: Date:

1. Did the headaches start after an accident, illness or infection? □ Yes □ No

2. How long has the patient had these headaches?

3. The headaches: □ Are constant □ Come and go

4. How often do the headaches occur? □ Daily □ Weekly □ Monthly

5. How many hours do the headaches last? ______________________________________________________

6. Do the headaches occur at a certain time of day? □ Morning □ Afternoon □ Night

7. Are the headaches becoming: □ Stronger □ Lasting longer □ Occurring more frequently

8. Do the headaches ever wake the patient up when they are asleep? □ Yes □ No

9. Does rest or sleep relieve the headache? □ Yes □ No

10. Do the headaches stop the patient from doing regular daily activities? □ Yes □ No

11. Has the patient ever missed work/school because of a headache? □ Yes □ No

12. Is the headache pain: □ Intense when it starts □ Starts out small and builds up

13. Please check all of the things that bring on the headaches:

□ Odors (Perfume, cigarettes) □ Fatigue □ School □ Hunger (missing meals) □ Loud Noises □ Anxiety or stress □ Exercise or playing □ Ice cream □ Family problems □ Too much sleep (sleeping in) □ Bright lights □ Menstrual cycle □ Too little sleep (staying up late) □ Sunshine □ Birth control pills □ Riding in a car □ Hot weather □ Alcohol

□ Medications Which ones?

□ Certain foods Which ones?

14. Is nasal congestion, sinusitis or allergies associated with the headache? □ Yes □ No

15. Are there any warning signs BEFORE the headache begins?

□ Paleness □ Mood swings (either high or low) □ Irritability □ Dizziness □ Tired, sleepy or yawning □ Increased appetite □ Rings around the eyes □ Hyperactivity □ Craving sweets □ Eye problems (Ex. blurred vision, black spots, flashing lights or double vision)

16. Where is the headache located?

□ Left side □ Forehead □ All around the head □ Right side □ Temples □ Top of the head □ Neck □ Back of the head If the pain is another part of the head, please describe or mark the location:

17. What does the pain feel like?

□ Exploding □ Sharp □ Throbbing/pounding (like a hammer) □ Dull □ Aching □ Pressure □ Tightness (like a rubber band wrapped around the head)

Please describe the pain in your own words:

18. Are there any other symptoms when the patient has a headache?

□ Nausea □ Stomach pains □ Weakness in the arms or legs □ Vomiting □ Confusion □ Numbness to the arms or legs

Sensitivity to: □ Light □ Odors/smells □ Noise/sounds

Other symptoms, please describe:

19. Name other family members who have/has had headaches, migraines, sick headaches, motion sickness, “brain freeze” from eating ice cream or had trouble taking birth control pills because of headaches.

20. Describe any major stresses in the last year. (Ex. marital changes, relocation, changes at work/school, death of a loved one) :

21. Has the patient been treated for headaches in the past? Please list the name of the treating provider and date of the treatment :

Were any of the following test performed during that treatment period? □ CT Scan □ Eye exam □ Sinus X-rays □ MRI □ Dental exam □ Allergy tests □ Spinal Tap □ Blood tests Other tests: :

22. What medication or treatments have you tried and failed? And how long did you try them for? (Ex. glasses allergy shots, chiropractor, herbal medicine, Mortin, Tylenol, prescription medications, etc)

23. What questions do you have about the patient’s headaches? What worries you the most? What medical tests, medicines or therapies would you like to know about?

Updated: August 2015

2335 E. Kashian Lane, Suite 301, Fresno, CA 93701 559.264.9100 // 559.264.9199 fax

Chronic Headache/Pain Diary

Patient Name:

Month: Year: Please fill in the dates of the month in the small boxes.

HEADACHE/PAIN SEVERITY: Please record the worst paint severity of the entire day. 0 = No Pain, 10 = Worst Pain

WOMEN: Please circle your menstrual cycle days.

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Pain = Pain = Pain = Pain = Pain = Pain = Pain =

Pain = Pain = Pain = Pain = Pain = Pain = Pain =

Pain = Pain = Pain = Pain = Pain = Pain = Pain =

Pain = Pain = Pain = Pain = Pain = Pain = Pain =

Pain = Pain = Pain = Pain = Pain = Pain = Pain =