Headache History And Profile Form (Page 2 of 2) in pdf

Headache History And Profile Form Page 2

HEADACHE HISTORY & PROFILE (continued)

Indicate if any of the following factors have (√) brought on (trigger) or (x) worsen your headache –

__Missed meal

__Head injury

__Change in weather

__Mediations

__Sleep-too much-too little

__Seasons –

__Emotional stress __during __after

_Allergies __MSG

__Menstrual periods

__Depression – anxiety

__Processed meats

__Other ___________

__Physical activity

__Chocolate __Citrus Fruits

__Sitting up

__Cheeses

__Bending over

__Caffeine

__Straining – coughing

__Other foods

Do any blood relatives have severe headaches? _ No _ Yes Who & Diagnosis -

Which of the following makes the headache better? __Rest

__Activity

__Darkness __Quiet

__Compresses __Tylenol / Motrin

__sleep

_Scalp or temple pressure

__Other___________________________________

Have you been sad or worried about anything?

Previous professional treatment of headache?

_ No

_ Yes – Who & When –

Previous x-ray or other investigations of headache? _ No

_ Yes – Describe –

Previous medications for headache? _ No

_ Yes

Name – dosage

Other current medications?

Please list – include over the counter drugs

DRUG ALLERGIES

ADDITIONAL NOTES

Headache History And Profile Form Page 2