New patient with headache questionnaire

Patient History
Name
Marital Status □S □M □W □Div □Sep Referred by: □primary care physician □other neurologist □family member □friend □other Please provide your referring or regular doctor’s full name, address, phone number, and fax number.
All of this information is required in order to mail or fax a letter to your doctor.
Referring Physician or Primary Care Doctor:

Headache History
Do You Have More Than One Headache Type? □Yes □No
Briefly describe headaches here:
Onset Of First Headache:
Headaches started ____ years ago. I was: _____ years old.
Precipitating Event (what provoked you first headache):
Location of Pain:
Sidedness:
Changes Sides:
□During Attacks □Both between and during Pain Characteristics:
6. (a) Severity: (How bad is the pain on a scale of 0 to 10: where 0 is no pain and 10 is the worst)
Lowest and highest level of pain for this headache: Low_____ to High ______ Usual severity of this headache type: ________ Worse with your period? (b) Headache disability during or after an attack:
Duration: (How long do they last?)
Lasts ___minutes ___hours ___days (with medication) | How often does it recur within 24 hrs?____% Lasts ___minutes ___hours ___days (without medication) | How often does it recur within 24 hrs?___% Frequency: (the number of attacks)
____#/day ____#/week ____#/month ____# per year ____# of lifetime attacks ____continuous
(a) How many days in the last month did you experience headaches? (This includes all days of head or
facial pain whether it be mild, moderate, or sever in intensity) _________days per month

(b) Based on your answer to question (a), how many of these days are your headaches moderate to severe
in intensity? (For example, you may experience 20 days of headache per month, of which only 10 are
moderate to severe in intensity)
_________days per month

(c) Are you ever HEADACHE FREE? □Yes □No
□Pregnancy □Vacation □Weekends □Random □Remission □Other Premonitory Symptoms (you experience one or more of these symptoms before onset of headache):
Current Pattern:
Time of day:
□Morning □Afternoon □Evening □Night Are they more frequent:
□Seasonal □Spring □Summer □Fall □Winter Associated Symptoms:
Aura: Visual (Do you have these symptoms before your headache begins?)
Do the symptoms spread? □Yes-spreads slowly □No-begins all at once The visual symptoms start: □before headache pain □during headache pain □both before and during The visual symptoms last a total of: _______________. How long does the aura last before the head pain starts? ________________ How long does the aura and head pain last altogether? _________________ If you have more than one symptom, do they happen: □One after the other or □All at once? Do you have a visual aura without headache pain? □Yes □No Aura: Sensory
Does the sensory aura spread? □Yes-spreads slowly □No-begins all at once The sensory aura starts: □before headache pain □during headache pain □both before and during The sensory aura altogether lasts: ____________________. How long does the aura last before the onset of head pain? _________________ How long does the aura and head pain last, if both occur at the same time? __________________ If you have more than one symptom, do they happen: □One after the other or □All at once? Do you experience sensory aura without headache pain? □Yes □No Provoking Factors: (things that bring on a headache)
Food/beverage: □Fasting □Chocolate □Caffeine □Nitrates □MSG □Alcohol beverages________________ □Wine: [□Red □White] □Other:_____________ Physical exertion: □Coughing □Talking □Chewing □Exercise □Sexual intercourse Hormonal: Menses: □Before □During □After Stress: □Work □Home □Family □Spouse □Other:________________________________ Environmental: □Allergies □Weather changes □Altitude □Sunlight □Other:____________ Sleep: □Lack of sleep □Too much sleep □Change in wake/sleep Activity that worsens headache:
Relieving Factors:
Do you have a second type of headache?
Please describe:

18.
Do you have any allergies to medications?
Part 1: Please circle any medicines that you have taken for your headache
Part 2: Please circle any medications that you have taken for your headache
Medication List
Please list ALL medications currently taken; include over the counter medications (such as Tylenol, advil, Excedrin, etc.), herbs, supplements, and vitamins. a. In Column “A”, please write each medication you use b. In Column “B”, please write the number of milligrams of the medication you take c. In Column “C”, write the number of times you take each medication per day. (i.e. 1 pill 2 Previous Treatments and testing:

Previous Treatments (Please give name of provider, date, type of treatment and if it helped)
□Primary care provider_______________________________________________________ □Neurologist_______________________________________________________________ □Otolaryngologist (ENT) _____________________________________________________ □Dentist/dental______________________________________________________________ □Chiropractor_______________________________________________________________ □Ophthalmologist____________________________________________________________ □Psychiatrist/psychologist_____________________________________________________ □Biofeedback/relaxation_______________________________________________________ □Physical therapy____________________________________________________________ □Massage__________________________________________________________________ □Acupuncture/acupressure_____________________________________________________ □Herbal/homeopathic medicine_________________________________________________ □Other: ___________________________________________________________________ Previous Tests (Please give data and results)
Past Medical History
General Health: □Excellent □Good □Fair □Poor
Have you had any of the following medical problems?
Have you ever been hospitalized or had SURGERY? (List reason, date, hospital)
Reason for Hospital Stay
Hospital
Menstrual History:
Are you still menstruating? □Yes □No If not monthly, every________________________ Reason for menopause:______________________ Premenstrual symptoms:__________________________________________________________ Obstetrical History
Total pregnancies:________________
Current method of contraception:________________________________________ Quality of Life Review:
Over the last 2 weeks, how often have you been bothered by the following problems? (check one in
each column)
Not at all
More than
every day
Not being able to stop or control worrying Worrying too much about different things Being so restless that it is hard to sit still Feeling afraid as if something awful might Over the last 2 weeks, how often have you been bothered by any of the following problems?
(check one in each column)
Not at all
More than
every day
Little interest or pleasure in doing things Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Feeling bad about yourself, or that you are a failure, or have let yourself or your family Trouble concentrating on things, such as people could have noticed. Or the opposite - being so restless that you have been moving Thoughts that you would be better off dead, or I get ____hours of sleep per night.
□I wake up during the night or early morning for no My sexual function is: (check all that apply)
□normal □no change □increased libido □decreased libido □no orgasms □problems with erections □Other:____________________________________ HEADACHES EFFECT ON ABILITY TO FUNCTION: (Do your headaches affect?)
Record number of days missed per month of work/school and or social and family activities ____#/days/month missed ____#/days/month missed Social History:
Living in: □home □apartment □other:_____________ Living in household: _____# of people _____# of children _____# of children <18 □Some high school □HS graduate or GED □Some college □College degree □Post graduate school □Grade________ □Other:_________________ Employment Status: □Part-time □Full-time □Retired □Disability □Other:__________ If disabled, why?_______________________________________
Risk Factors:
I drink or drank: #_____Alcoholic beverages per □day □week □month □marijuana □cocaine/crack □heroin □other:___________________ Year began:_________ Year stopped________ I smoke/d _______ Cigarettes per □day □week □month I drink _______ Caffeinated beverages (coffee/tea/cola) per □day □week
Lifestyle Factors:
Do you exercise? □No □Yes _______X a week Are you on any special diet? □No □Yes ________________________________________________________ Any recent weight loss/gain? □No □Yes Describe diet or weight change:_____________________________________
Family History:
Please fill out below. If deceased, give age and cause of death Siblings__________________________________________________ Review of Systems:
Have you been having any of the following symptoms not associated with your headache?
You can use this space to describe anything you feel is important that was not covered in this
questionnaire.
_______________________________________________________________________________________
Patient’s signature____________________________________ Date:_______________________
History reviewed: □No changes □Additions as noted
Physician’s signature__________________________________ Date:_______________________

Source: http://www.neurosurgeonsofnewjersey.com/wp-content/uploads/2011/04/Altschul_new_patient_headache.pdf?62d590