Headache History And Profile Form printable pdf download

HEADACHE HISTORY & PROFILE

NAME

DATE OF BIRTH

TODAY’S DATE

Where are your headaches located? On what part of the head do the headaches start?

__(R) Side

__(L) Side

__Either side

__Both sides

__Back

__On top

__Temples

__Behind / around eyes

__Forehead

__Face

__Neck

__Other –

After the headache starts – Does it usually – Stay in one place ___

Move around ___

Please explain –

How would you describe the pain? -

__Throbbing / pulsating

__Pressing / squeezing

__Stabbing

__Sharp

__Dull / nagging

__Other –

Describe the degree of pain (circle one #) – slight – 1 2 3 4 5 6 7 8 9 10 – worst imaginable

Do your headaches interfere or prevent normal activities – school, work, etc.? _ No _ Yes, If so how many days have been missed? ___

How long ago did the current headache start?

__Weeks

__Months

__Years

How old were you when any headache started? ________

How long does the headache usually last?

__Minutes

__Hours

__Days

__Constant

How often does the headache occur?

__x / Day

__x / Week

__x / Month

__x / Year

__Constant

Does the headache awaken you from sleep? _ Yes

_ No

Is the headache getting

__worse

__better

__fluctuating

__no change

Are any of the following symptoms associated with the headache? Please mark (B) before (√) during (A) after

__Spots before eyes – type –

__Nausea

__Vomiting

Weakness (W) Numbness (N) Both (B)

__Blindness (R L)

__Loss of appetite

__Hunger

__Face (R L)

__Arms (R L)

__Blurring (R L)

__Cramps

__Diarrhea

__Arm & leg (R L)__Legs (R L)

__Double vision

Face – Scalp –

__Pale __Redness

__Difficulty talking (finding words)

__Can see only half of objects

__Sweating

__Tender

__Difficulty understanding

__Eyelid droop (R L)

__Puffy __Pain on chewing

__Numbness around lips

__Tearing (R L)

__Decreased jaw opening

__Slurred speech

__Eye redness (R L)

Neck -

__Fainting (feel like or have fainted)

__Eyes puffy (R L

__Stiff __Tender

__Dizzy (lightheaded – unsteady –

__Light sensitivity

__Difficulty concentrating

spinning)

__Noise sensitivity

__Depression

__Anxiety

Hands and / or feet –

__Odors sensitivity

__Fatigue

__Irritability

__Cold __Pale

__Nose blocked / discharge (R L)

__Sweaty

__Mottled

Headache History And Profile Form

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