Headache Intake Assessment Form

Headache Intake Assessment FormName: _______________________________________________Date:____________________Age: __________ Sex: M F Marital Status __________________________________Name of Spouse: _______________________________________________________________Name(s) and Age(s) of children:_________________________________________________________________________________________________________________________________Names & Types of Pets: __________________________________________________________Education: _____________________________________________________________________Occupation: _____________________________ Spouse’s occupation: _____________________Does anyone in your family have headaches, or have they had moderate-to-severe headaches inthe past? ______________________________________________________________________How old were you when you started having headaches? _________________________________How often do you have a mild -moderate headache? ____________________________________How often do you have a severe headache/ migraine? ___________________________________How long do the severe headaches last? __hours __one day __ two days __three or more daysOn a scale of one to ten, ten being the worst, how severe are the headaches?1 2 3 4 5 6 7 8 9 10Mild Moderate SevereDo you have some type of headache every day? _______________________________________How much do these daily headaches bother you? Mildly _____ Moderately _____ Severely ____Where does the pain occur for your daily headaches? ___________________________________Where does the pain occur for your severe headaches/migraines? __________________________What does your headache typically feel like? ( please circle one)Throbbing/pulsing Pressing/squeezing sharp/stabbing dull/achyDoes your eye tear on the side of the headache? Yes NoAre the headaches much worse in the last few months? Yes NoAre the headaches much worse in the last year? Yes NoDo you frequently have nausea with your headaches? Yes NoDo you typically have visual problems with your headaches; such as flashing lights, sprinkles oflight, or vision loss on one side? Yes NoDo you typically experience sensitivity to light? Yes NoDo you typically experience sensitivity to sound? Yes NoAre your headaches worse before or during your menstrual cycle? Yes NoDo you take any birth control pill or hormone? ________________________________________

Circle the following if these play a role in yourheadaches or in producing an occasional headache:stressafter stress is overweather changesfoodsbright sunlightsexual activityunder sleepingoversleepinghormonal changesmenstrual cycleexerciseexertionmissing a mealcigarette odorperfume odorsdifferent seasons:summerfallwinterspringDo you have very cold feet and hands in the winter? _____________________________________Have you had any of the following tests?CT scan for your headaches? Y or N If so, when? _______________Results ______________MRI for the headaches? Y or N If so, when? _______________ Results ______________Blood tests in the past year? ___________________ Were they normal? _____________________Have you tried Biofeedback or relaxation training for headaches? Yes NoIf yes, has it helped? ____________________________________________________________________________________________________________________________________________How much do you exercise, and what do you do? _____________________________________________________________________________________________________________________Which doctors have you seen for headaches, if any? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Which family doctors or other doctors do you see? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you smoke cigarettes? Yes No If yes, how many______________________________Do you drink alcohol? Never Occasionally DailyHave you had any type of problem with addictive drugs in the past? ________________________Do you tend to be anxious or nervous? Yes NoIf yes, is your anxiety mild, moderate, or Severe? _______________________Do you have trouble Sleeping? Y N If yes, do you have trouble going to sleep? Or stayingasleep? _______________________________________________________________________Do you have a history of depression? Y or N If yes, when was your last episode? ___________Is/was it: Mild Moderate or SevereOther past medical history:Operations? ___________________________________________________________________________________________________________________________________________________Ulcers or stomach problems? _____________________________________________________________________________________________________________________________________Asthma? _____________________________________________________________________________________________________________________________________________________Any other medical problems? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Side effects or allergies to any medications? _______________________________________________________________________________________________________________________________________________________________________________________________________What medications are you currently taking? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________