Headache Questionnaire

Part 1: About you
Patient Name*
Date of Birth*
Date Format: YYYY dash MM dash DD
Email*
Phone*
Questionnaire
1. What is the reason for your visit? (Check all that apply)*
- Head pain
- Face pain
- Neck Pain
- Dizziness
- Other
2. Pain Characteristics:
How old were your when your first ever head/face pain started?*
Please enter a number greater than or equal to 0.
When did the current headache/face pain start?*
What do you attribute it to?*
- Head injury
- infection
- Family history/genetics
- After a procedure
- I don’t know
Current number of head/face pain days per month:*
Please enter a number greater than or equal to 0.
If headaches/face pain are daily, how long ago did they become daily?
Average duration of headache/face pain attacks in hours*
- they are daily
Onset of headache/face pain to peak intensity*
- Seconds
- Minutes
- Hours
- N/A
Average duration of Headache / Face Pain ( Write in seconds / minutes / hours / days )*
- Morning
- Afternoon
- Evening
- During sleep
- All day
Do these symptoms wake you up in the middle of your sleep ?*
- Yes
- No
3. Location of pain: (Check all that apply)*
- Right front of head
- Left front of head
- Tight temple
- Left temple
- Right back side of head
- Left back side of head
- Right face
- Left face
- Other
- Not applicable
4. Quality of Pain: (Check all that apply)*
- Throbbing / Pounding
- Shooting
- Zapping
- Electric
- Burning
- Aching
- Tingling / pins & needles
- Dull
- Hot
- Crushing
- Exploding
- Squeezing
- Pressure
- Sharp
- Thunderclap
- Other
5. Average Intensity of head/face pain from 1-5:*
- (1 = Mild).
- (2 = Moderate, uncomfortable. Can still work/study, enjoy social activities)
- (3 = Severe, interrupts work/study, house chores)
- (4 = incapacitating, unable to work/study)
- (5 = most extreme, unimaginable, bedridden)
6. What are the Triggers?*
- Exercise/exertion
- Weather changes
- Oversleep
- Under sleep
- Strong smell
- Alcohol
- Certain foods
- Missing meals
- Sexual intercourse / Orgasm
- During/around menses
- Air travel/long distance car travel
- Flashing lights
- Alcohol
- Sudden neck movements
- Coughing
- Sneezing
- Straining in the toilet
- bending over
- light touch
- Cold/hot wind on face
- Brushing teeth
- Shaving
- Make-up
- Chewing
- Other
Please explain*
7. Associated symptoms during headache/face pain*
- Light
- Sound
- Smell
- Nausea
- Vomiting
- Motion Sickness
- Stuffy Nose/Nasal Congestion/Nasal Drainage
- Watery Eyes
- Eye Droop
- Leg Weakness
- Arm Weakness
- Leg Numbness
- Arm Numbness
- Slurred Speech
- Difficulty Getting Words Out
- Scalp Soreness to Touch
- Ringing in Ears
- Ear fullness / Clogging feeling
- Fainting
- Seizure
- Confusion
- Memory Problem
- Face Pain
- TMJ Dysfunction / Pain
- Pacing / Restlessness
- Face Flushing
- Other
8. Positional Component
What happens to your headache when you stand up?*
- No change
- Better
- Worse
What happens to your headache when you lay down flat?*
- No change
- Better
- Worse
9. Visual symptoms with headache?*
- Yes
- No
9.1 Please Explain*
How long do they last?
Days
Minutes
Hours
Intermittent throughout the day
Which vision pattern do you see?*
- Blurred vision
- Double vision
- Zig zag lines
- Cloud
- Checkerboard pattern
- Kaleidoscope
- Arc shape
- Tunnel Vision
- Blind / White / Black spots
- Other
10. Did you feel dizzy in the last 4 weeks?*
- Yes
- No
Describe the sensation*
- Vertigo (room spinning)
- imbalance / being on a boat feeling
- Lightheaded when standing up
- Other (Explain)
Dizziness duration*
- Constant
- Comes and Goes
If it comes and goes, what is the duration of the longest and shortest attacks? Give range
Other symptoms associated with dizziness*
- Feeling of passing out
- Ringing in Ears
- Hearing loss
- Warm sensation, sweaty, clammy
- Palpitations
11. Misc. Questions
Weight gain in last 6 months:*
- Yes
- No
Neck pain*
- Yes
- No
Days per week*
Pain elsewhere?*
- Yes
- No
Where?*
Birth Control?*
- Yes
- No
What type?*
- Pills
- Skin Implant
- Condoms
- Uterine device
- Other
Current stressors?
- Job
- Studies
- Relationship
- Finance
- Sick family member
- Recent death of loved one
- Ongoing medical problems
- None
- Other
What Type*
- Physical
- Emotional
- Sexual
- Verbal
- Flashbacks of witnessed traumatic incident
History of motion sickness as a child?*
- Yes
- No
History of head or neck trauma/concussion?*
- Yes
- No
Explain*
Ever had loss of consciousness?*
- Yes
- No
Explain*
Which headache / dizziness/ face pain specialists have you seen in the past?*
Have you ever been treated at a drug/opiate/alcohol rehab facility*
- Yes
- No
14. Do you have the following medical diagnosis?
- Stroke
- Brain hemorrhage
- Clot in legs/lungs
- Heart attack
- Lupus
- Stomach ulcer
- Brain aneurysm
- Depression
- Anxiety
- Bipolar disorder
- Schizophrenia
- PTSD
- ADHD
- Diverticulitis
- Seizures/Epilepsy
- Concussion
- Traumatic brain injury
- Diabetes
- Hypertension
- Chronic kidney disease
- Kidney stones
- Glaucoma
- Asthma
- Atrial Fibrillation
- Pancreatitis
- Fibromyalgia
- Irritable bowel syndrome
- Liver disease/Hepatitis
- Thyroid disease
- Cancer
- Lyme’s disease
- Chronic fatigue syndrome
- Interstitial cystitis
- Ehlers Danlos Syndrome
- CSF leak
- Pseudo tumor cerebri/ idiopathic intracranial hypertension
- Obstructive sleep apnea
- Brain tumor
- POTS
- Vasculitis
- Giant cell arteritis
- sarcoidosis
- BPPV
- Dementia
- Arnold Chiari
15. List any other medical conditions and the year of diagnosis:*
16. List all the previous surgeries including the year*
18. List other medical problems in family*
Headache sufferer in your family?*
Family history of brain aneurysms?*
- Yes
- No
19. Social/Demographics:
a) Have you ever been a smoker?*
- Yes
- No
b) Do you currently smoke?*
- Yes
- No
c) How many caffeinated beverages per day?*
Please enter the name (what kind)?*
d) Do you drink alcohol?*
- Yes
- No
How many alcohol drinks per week?*
f) Recreational/street drugs?*
- Yes
- No
Please name*
g) How many days per week do you exercise?*
h) Marital Status*
i) Your profession:*
j) Work status*
- Full-time
- Part-time
- Homemaker
- Retired
- Student
- Disabled
20. List all your current medicines with doses
21. Most recent
BP*
Pulse*
Weight in Lbs*
Height*
22. Within the last 12 months, have you used any of the following drugs for pain?
NSAIDS [ Ibuprofen (Advil), Naproxen (Aleve), Meloxicam , Celecoxib (Celebrex) , Ketorolac (Ketorolac), Diclofenac (Voltaren, Cambia), Aspirin, Indomethacin ( Indocin) ]
Please enter a number greater than or equal to 0.
TRIPTANS/ERGOTS [ Sumatriptan,(Imitrex), Rizatriptan (Maxalt), Naratriptan (Amerge), Zolmitriptan (Zomig), Eletriptan (Relpax), Frovatriptan (Frova) Almotriptan (Axert), Treximet, DHE injection, Trudhesa nasal spray, Methergine ]
Please enter a number greater than or equal to 0.
OPIATES/NARCOTICS [ Hydrocodone (Vicodin, Norco) Fentanyl patch, Tylenol#3, Oxycodone (Percocet), Morphine, Dilaudid, Subaxone, Methadone, Tramadol, Stadol nasal spray, Nucynta, Codeine, Belbuca, Other opiate ]
Please enter a number greater than or equal to 0.
MISC (Excedrin, Tylenol, Fioricet, Fiorinal, Midrin, Marijuana , Lasmiditan (Reyvow))
Please enter a number greater than or equal to 0.
23. Have you ever used the following drugs in the past?
Anti-depressants
- Amitriptyline
- Nortriptyline (Pamelor)
- Protriptyline
- Venlafaxine (Effexor)
- Pristiq
- Cymbalta
- Remeron (Mirtazapine)
- Trazodone
- SSRIs
- Lithium
- Abilify
- Seroquel
- Trazodone
Anti-hypertensives
- Propranolol (Inderal)
- Nadolol
- Metoprolol
- Timolol
- Carvedilol
- Verapamil
- Amlodipine
- Nifedipine
- Nimodipine
- Candesartan
- Clonidine patch
- Lisinopril
- Losartan
- Lasix
Anti-seizure class
- Topiramate (Topamax)
- Trokendi
- Gabapentin
- Lyrica
- Zonisamide
- Lamotrigine (Lamictal)
- Valproate (Depakote)
- Dilantin (Phenytoin) Carbamazepine (Tegretol)
- Oxcarbazepine (Trileptal)
- Eslicarbazepine (Aptiom)
- Keppra
- Clonazepam
- Xanax
- Valium
- Diamox (Acetazolamide)
Muscle relaxants
- Baclofen
- Flexeril
- Robaxin
- Skelaxin
- Tizanidine
- Soma
- Lorzone
Anti-CGRP Drugs
- Aimovig
- Emgality
- Ajovy
- Qulipta
- Nurtec
- Ubrelvy
Steroids
- Prednisone
- Dexamethasone
- Cortisone
- Fludrocortisone
- Hydrocortisone
Misc
- Memantine (Namenda)
- Zofran
- Hydroxyzine
- Warfarin
- Xarelto
- Naltrexone
- Ritalin
- Amphetamine
- Compazine
Supplements
- Vit B2 (Riboflavin)
- Magnesium
- CoQ10
- Butterbur
- Feverfew
- Gliacin
IV Infusions
- IV DHE
- IV Ketamine
- OR Ketamine Nasal spray
- IV Lidocaine
- IV VYEPTI
- IV Steroids
- IV Reglan
- Toradol
- Benadryl
Besides above, any other drug that you have tried for headaches/face pain/ Dizziness?
24. Have you used the following devices?
- Cefaly
- Gamma core (Vagus nerve stimulator)
- TENS unit
- Nerivio migra wearable device
25. Have you ever had the following procedures? Please check.
- Botox
- Occipital nerve blocks in back of head
- Supraorbital blocks in the forehead
- SPG (sphenopalatine ganglion block) via nose.
- X-ray/Fluoroscopy guided neck blocks (Epidural, Facet blocks in the neck, radiofrequency ablation)
- Trigeminal Nerve Block (For Trigeminal Neuralgia)
- Trigger point injections.
- Physical therapy of head/neck.
- Rhizotomy
- Gamma knife
- Psychologist eval for chronic pain.
- Nasal sinus surgery
- Occipital nerve decompression surgery
- Nerve stimulator implant
- Stellate ganglion block
- Fibrin glue patch
- Occipital nerve stimulator implant
26. When was the last time you had the following tests?
MRI/MR Angio Brain
Please enter a number greater than or equal to 1990.
CT Head /CT Angio Head
Please enter a number greater than or equal to 1990.
MRI Neck
Please enter a number greater than or equal to 1990.
MR/CT Venogram Head
Please enter a number greater than or equal to 1990.
Lumbar Puncture
Please enter a number greater than or equal to 1990.
Blood patch
Please enter a number greater than or equal to 1990.
27. Anything else you want to add?*
Person completing form*
Attach Files (If Any)

Part 1: About you

Questionnaire

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