NAME Date Headache Questionnaire
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1 NAME DATE Headache Questionnaire DIRECTIONS: Please answer all questions to the best of your ability 1. What is your main headache-related problem: (check only one) a. Headaches b. Headaches and neck pain c. Face pain d. Neck pain 2. When in your life did you first have any kind of headache: a. Childhood d. 40 s b.teenager e. 50 and over c. 20 s 30 s Age of onset if known 3. Have you previously been diagnosed with: a. Migraine 1. YES 2. NO b. Tension headache 1. YES 2. NO c. Sinus headache 1. YES 2. NO d. Cluster headache 1. YES 2. NO e. Headache from neck 1. YES 2. NO f. Trigeminal neuralgia 1. YES 2. NO g. Other: 4. Where is your pain located: (check all a. HEAD: 1.left side 5. top of the head 2.right side 6. back of the head 3.forehead 7. all over 4.temples 8. Location varies
2 Headache Questionnaire page 2 Where is your pain located (cont.): b. NECK: 1. left neck 2. right neck 3. both sides 4. none 5.What does your pain feel like: (check all 1. steady 2. dull 3. aching 4. throbbing 5. pressure-like 6. tightness/band-like 7. exploding 8. Sharp/stabbing 9. Intense Describe your pain in your own words: 6.In the past 3 months are your headaches becoming: (check all 1.stronger/more severe 2.longer lasting 3.more frequent 4.about the same 5.not as bad 7.How many TOTAL headache days have you averaged over the past 3 months: (pick one best answer) Do the headaches awaken you from sleep: YES NO
3 Headache Questionnaire page 3 9. Does rest or sleep relieve or stop your headache: YES NO 10. Do any of the following physical activities trigger a headache, head pain or face pain: (check all 1.coughing 2.sneezing 3.bending over 4.straining 5.lifting 6.exercise 7.sexual activity 8. Standing up 9. Laying down 10. chewing 11. swallowing 12. talking 13. laughing 14. Touching the face 11. Do any of the following seem to trigger your headache: (Check all 1. stress 9. loud noise 2. alcohol 10. change in the weather 3. odors(e.g. perfume, smoke) 11. heat/hot weather 4. hunger/not eating 12. cold/ice cream 5. too much sleep 13. Allergies 6. too little sleep 14. Sinuses 7. fatigue 15. School/exams 8. bright light/sunshine 16. Foods (name) 17. Medications (name) 12. What makes the pain BETTER (check all 1. rest 5. laying down 2. darkness 6. standing up 3. quiet 7. taking medication 4. cool temperature 8. Other
4 Headache Questionnaire page Which of the following are likely to occur with your headache: (check all 1. sensitivity to light 2. sensitivity to loud noise 3. sensitivity to odors 4. nausea 5. nausea and vomiting 6. diarrhea 7. feel lightheaded or dizzy 8. neck is stiff/sore 9. feel confused/disoriented 10. blurred vision 11. numbness 12. weakness 13. one eye tears 14. both eyes tear 15. nose runs 16. head is stuffed up 17. can t go to work/school 18. must leave work/school 14. FEMALE ONLY A. Do your headaches occur or get worse around the time of your period(menses)? 1. YES 2. NO B. Have you taken Birth Control Pills or replacement estrogen for menopause or after hysterectomy? 1. YES 2. NO If YES, did headaches get worse, better or no change? 1. WORSE 2. BETTER 3. NO CHANGE 15. Do any of the following occur just before your headache starts: (check all 1. blurred vision 7. numbness 2. black spots 8. tingling 3. wavy lines 9. weakness 4. flashes or sparkling lights 10. trouble speaking 5. bright lines and/or colors 11. dizziness/vertigo 6. zig zag lines 12. double vision Other
5 Headache Questionnaire page Do you have warnings that start hours or days before you get a headache: (check all 1. dizziness 5. food cravings 2. mood changes 6. sleepiness 3. irritability 7. yawning Other 17. Did your headache, head pain or neck pain start after : Accident/ injury Illness/ infection Traumatic life event Date Date Date 18. Who else in your family has had HEADACHE OF ANY KIND: (check all 1. mother 5. children 2. father 6. grandmother 3. sister 7. grandfather 4. your children 8. uncle/aunt 19. Have you been to an Emergency Room or Urgent Care Clinic for headache/head pain treatment: 1. YES 2. NO If yes, how many times in the past year: 1.none 2.one time times 4.more than 3 times
6 Headache Questionnaire page Which of the following treatments have you tried in the past or are using currently: (check all 1. relaxation/biofeedback 11. exercise 2. massage 12. dieting 3. physical therapy 13. meditation 4. chiropractic/manipulation 14. yoga 5. osteopathic 15. hypnosis 6. naturopathic 16. trigger point injections 7. acupuncture 17. nerve blocks 8. psychotherapy 18. change work/school routine 9. counseling 19. surgical procedures 10. TMJ treatment 20. pain management program 21. Have you experienced any of the following in the PAST: (check all that apply) 1. unhappy childhood 2. abuse (emotional, verbal, physical, sexual) 3. separation or divorce 4. depression 5. job loss 6. prolonged illness/disability 22. Do you CURRENTLY have any of the following stresses: (check all 1. spouse/partner relationship problems 2. family relationship problems 3. separation/divorce 4. job loss/unemployment 5. financial problems 6. legal problems 7. abuse 8. trouble at work or school 9. loneliness/isolation
7 Headache questionnaire page Have you had any of the following tests for your headache/head pain problem: (check all 1. eye exam 6. blood tests 2. MRI head scan(where: ) 7. allergy tests 3. MRI neck scan(where: ) 8. spinal tap 4. CT head scan 9. sinus exam or x-rays 5. psychological testing 10. dental evaluation 24. When you have pain which of these medications have you tried: (check all A. Over the Counter B. Prescription Migraine C. Prescription Pain 1. aspirin 1. sumatriptan(imitrex) 1.Vicodin/Norco 2. ibuprofen(advil) 2. Maxalt 2. oxycodone/percocet 3. naproxen(aleve) 3. Zomig 3. hydromorphone 4. Excedrin/Anacin 4. Relpax (Dilaudid) 5. acetaminophen 5. Frova 4. morphine (Tylenol) 6. Axert 5. Fiorinal/Fioricet 6. sinus medicine 7. Naratriptan(Amerge) 6. Darvon/Darvocet 7. allergy medicine 8. DHE Tylenol with codeine 8. Canadian pain 9. indomethacin 8. Demerol pills s 10. Metoclopramide 9. Actiq lollipops 11. Midrin 10. tizanidine 12. Cafergot 11. oxygen 13. Migranal 25. What medications have you tried to PREVENT headaches: (check all 1. amitriptyline/nortriptyline 11. Botox 2. propranolol/beta blockers 12. Effexor 3. topiramate(topamax) 13. Cymbalta 4. zonisamide(zonegran) 14. carbamazepine(tegretol) 5. valproic acid(depakote) 15. oxcarbazepine(trileptal) 6. verapamil/calcium blockers 16. magnesium or Vit B2 7. gabapentin(neurontin) 17. Namenda 8. cyproheptadine 18. feverfew 9. Lyrica 19. butterbur(petadolex) 10. levetiracetam(keppra) Other:
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Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail
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CHIEF COMPLAINT: Please number your symptoms (1 is the most severe) that you have developed since the accident.
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INITIAL PATIENT QUESTIONNAIRE-
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General Information. Age: Date of Birth: Gender (circle one) Male Female. Address: City: State: Zip Code: Telephone Numbers: (day) (evening)
Kelly Bernstein, MS, LCDC, LPC Medical Center Psychological Services 7272 Wurzbach Road, Suite 1504 San Antonio, Texas 78240 Office: (210) 522-1187 Fax: (210) 647-7805 Functional Assessment Tool The purpose
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AON Physical Therapy & Wellness
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