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Microsoft word - ec headache symptom form.doc

SYMPTOM QUESTIONNAIRE
HEADACHES
Please fill out only the sections that apply to you. Skip sections that do not relate to your condition.
WHEN DO YOU USUALLY GET YOUR HEADACHES?


WHAT USUALLY HELPS YOUR HEADACHES?


DESCRIBE HOW YOUR HEADACHE USUALLY FEELS:
 Pounding

Where does most of your headache pain focus?
(Check all that apply)
 Neck area

If your head pain radiates, where do your headaches start?
 Neck area
If your head pain radiates, where do your headaches end?
 Neck area

Recently have your headaches been?

 The same,  Better,  Worse,  Unusually intense,  Unusual type or unusual location of headache
How intense are your typical headaches? (Use 0-10 intensity)
Pain Intensity

Headache
HEADACHE FORM (Continued)
How many headaches do you have typically in a week/month? How many hours long is a typical headache for you? How many pills do you take a month for your headaches on the average? ___________ Pills every month
 YES,  NO Have you seen other Doctors for your headaches? Please list and describe treatment and if it treatment helped. Also
indicate if you have had any brain scans, laboratory tests, or other diagnostic tests done to evaluate your headaches.
___________________________________________________________________________________________________________
MEDICATIONS:
Please check any medications that you have taken recently for your headaches or other conditions

Narcotics (Codeine, Demerol, Tylenol with Codeine,  Anti-inflammatory medications (Naprosyn, Meclomen, and Asthma drugs (Aminophylline, Theophylline)  Corticosteroids (Decadron or Prednisone)
Check any of the following that apply to you:

Headaches associated with shortness of breath or excessive exhaustion Headaches associated with numbness of face and/or tongue Headaches associated with arm or leg weakness You usually know your headache is starting soon by various symptoms such as visual or sensory feelings You see lights/spots in your vision 5-50 minutes before headache pain begins You are very sensitive to light or sound during or after headache You presently or recently had a fever. This fever began just before your headaches started or during headache. You had a rash, chills, fever, headache, and joint pain/swelling 2 weeks prior to your headaches starting.* Physical exertion makes your headache worse (climbing stairs, lifting, etc) Headaches start 3-4 hours after eating and/or your headaches improve after you eat Muscles in neck and shoulders are tight/stiff or sore prior to headache Headaches get worse when you have sustained poor posture Headaches begin or get worse when you rotate or twist your head and/or neck You get dizzy or black out when headaches occur Get tearing, face flushing, or nasal discharge during headache History of sinus infection, allergies, deviated septum, or other nasal disorders Bruise easily. Check this only if you notice that you have bruises that you don’t remember any injury from.* You eat or drink substances having caffeine (coffee, chocolate, or tea). Number cups per day:

Source: http://www.drbrendamorales.com/forms/Headache%20Symptoms.pdf

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