Headache Questionnaire

Identification

Name: Date of Birth: Social Security Number: Age: Sex: Male Female

Headache History

How old were you when you first began to have headaches bad enough to interfere with your daily activities? Have there been any recent changes in your headaches? Yes No If yes, when did this occur? Please specify the type of change: How many days in the last 30 days were you headache-free or nearly so? Are your headaches incapacitating? Yes No How many headache days did you have in the past 30 days? Of these, how many were severe? Do you have daily headaches? Yes No If yes, for how long? How long do your worst headache attacks last? 0-1 hr >1-3 hrs 4-12 hrs >12-24 hrs >24-48 hrs >48-72 hrs >72 hrs Constant

Symptoms

Do you experience any of the following with your headaches?

Triggers and Medical History

Do you know any triggers for your headaches? Yes No If yes, list triggers: Medical history:

Social History and Lifestyle

Do you smoke? Never smoked Current smoker Former smoker Do you consume alcohol? Never Occasionally Frequently

Treatments

List all medications you have used for headaches: