Microsoft word - ec headache symptom form.doc
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:
Where does most of your headache pain focus?
(Check all that apply)
If your head pain radiates, where do your headaches start?
If your head pain radiates, where do your headaches end?
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)
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.
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:
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