Headache Evaluation Form
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1Headache Evaluation Form
Client #__________________ Name ____________________________ Age_______
When you have headaches, how often do you……… (Circle one answer per question
)
1. Feel them coming on before they become headaches?
Never
Rarely Usually Always
2. Have moderate to severe pain?
Never
Rarely Usually Always
3. Have pulsating, pounding, or throbbing pain?
Never
Rarely Usually Always
4. Have worse pain on one side of your head?
Never
Rarely Usually Always
5. Have worse pain when you move, bend over or walk stairs?
Never
Rarely Usually Always
6. Have nausea?
Never
Rarely Usually Always
7. Have vomiting?
Never
Rarely Usually Always
8. Feel bothered by light?
Never
Rarely Usually Always
9. Feel bothered by sound?
Never
Rarely Usually Always
10. Need to limit or avoid daily activities?
Never
Rarely Usually Always
11. Want to lie down in a quiet, dark room?
Never
Rarely Usually Always
12. See zigzag lines, spots, or light flashes?
Never
Rarely Usually Always
To give your healthcare provider more complete information, please answer these additional
questions:
1. Do any immediate family members also suffer from headaches?
Yes
No
2. In your lifetime, have you had at least 5 headaches with the symptoms noted above? Yes
No
3. At what age did you first experience these headaches?___________________________________
4. On average, how often do you get these headaches? _____________________________________
5. Which medicine(s) do you take for your headaches? _____________________________________
Check all of the statements that are true:
1. My headache medicine does not make me pain free.
____
2. My headache medicine does not treat other symptoms (e.g., nausea, sensitivity to light).
____
3. I take my headache medicine more than 2 or 3 times per week.
____
4. My headache medicine makes me drowsy.
____
5. I take more than one kind of medicine for my headaches.
____
6. My headache may last 4 to 72 hours (untreated or unsuccessfully treated).
____
Check any of the following that ever bring on one of these headaches:
___Intense lights, smells, or sounds
____Too little sleep or too much sleep
___Weather changes
____Missed meals
___Allergies or sinus pain/pressure
____Lack of caffeine or too much caffeine
___Stress or tension
____Changes in mood/excitement
___Monthly menstrual cycle/hormonal changes
____Foods or alcoholic beverages
Client’s Signature:___________________________________________________Date:________________
TO BE COMPLETED BY STAFF
Assessment:
______________________________________________________________________________________
Clinician Signature
Date
Agency Name
Adapted from: The American Journal of Nurse Practioners April 2004 Vol. 8 No. 4
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Parent category: Life