Days ago
Weeks ago
Months ago1.) When Did your pain start?
Days ago
Weeks ago
Months ago
Years ago
At approximately the age of ___
2.) Is the pain
Slight
Moderate
Severe
3.) On a scale of 1 - 10 (1 being slight, 10 being the worst pain you've had),
how would you rate your pain today? ___
4.) On a scale of 1 - 10 (1 being slight, 10 being the worst pain you've had),
how would you rate your pain on average
this past week? ___
5.) On a scale of 1 - 10 (1 being slight, 10 being the worst pain you've had),
how would you rate your pain on average
this past month? ___
6.) Do other members of your family have headaches? Y
N
7.) Did the pain begin...
Slowly
All of a sudden
8.) Do you know what started the pain? Please tell us if you do...
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9.) Does the pain feel like it is...
Dull/Aching
Pulsing
Burning Sharp
stabs Electrical
10.) When you get the headache, do you want to lie down in a dark room? Y N
11.) Does the pain start from the jaw and refer to...
Temples
Head
Neck
12.) Does the pain start from the neck and refer to...
Back of head
Top of head
Front of head
Between the
eyes or nose
The teeth Can't
tell
13.) Please place a checkmark beside the feelings/symptoms your experience
during your headache...
Visual changes
Nausea
Sensitivity to light
Sensitivity
to sound Sensitivity
to smell Swelling
14.) Does your headache feel like it happens regularly around your period? Y N
15.) Does the pain feel like it is squeezing like a band around your head? Y N
16.) Does the pain feel like it is intense around the face, skin, inside the
month and is
triggered by light touch of wind?
Y N
17.) In the course of a day how many times do you get pain?
1 - 5 per
day 1 - 15 per
day Other ___
18.) Does the pain last seconds to minutes? Y N
19.) Does the pain last minutes to about an hour? Y N
20.) Does the pain wake you from your sleep? Y N
21.) Do you feel anxious and want to move around? Y N
22.) Does your nose get runny? Y N
23.) Do your eyes get teary? Y N
24.) Is the pain present....
Daily
Weekly
Monthly For
a prolonged amount of time
25.) Is the pain always there and never changes except to get worse and affected
by
the position of your body?
Y N
26.) Does the pain feel like it went away for...
Weeks
Months
Years
27.) ...and when the pain went away, did it come back? Y N
28.) How many kinds of headaches do you get? Please describe them...
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29.) Did the pain use to feel like it used to be occasional and more intense,
but now it is less painful and always there?
Y N
30.) Have you ever stopped taking your medicine and found that the pain became
severe until you took the medicine again?
Y N
31.) Would you like to add anything you would like the doctor to know about
the pain?
Or anything else?
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