Neurology Headache Questionnaire printable pdf download

Neurology Headache Questionnaire

Patient’s Name:

Date:

1. Did the headaches start after an accident, illness or infection?

2. How long has the patient had these headaches?

3. Are the headaches constant or do they come and go?

4. How often do the headaches occur? (daily, weekly, monthly)

5. Do the headaches occur at a certain time of the day? ______morning

______afternoon ______night

6. Are the headaches becoming stronger, lasting longer or occurring more frequently?

7. Do the headaches ever wake up the patient up when he is sleeping?

8. Does rest or sleep relieve the headache?

9. Do the headaches stop the patient from doing things? (like playing, watching TV, going outside or doing homework.)

10. Has the patient ever missed school or work because of a headache?

11. Is the headache pain intense when it starts, or does it start out small and builds up?

12. Please check all of the things that bring on the headaches:

_____Odors (Perfume, cigarettes)

_____Fatigue

_____School

_____Hunger (missing meals)

_____Loud noises

_____Anxiety or stress

_____Exercise or playing

_____Ice Cream

_____Family problems

_____Too much sleep (sleeping in)

_____Bright Lights

_____Menstrual cycles

_____Too little sleep (staying up late)

_____Sunshine

_____Birth Control Pills

_____Riding in a car

_____Hot weather

_____Alcohol (wine, beer)

_____Medications

Which ones?

_____Certain foods Which ones?

(for example: chocolate, peanut butter, eggs, milk, pizza, etc.)

13. Are nasal congestion, sinusitis or allergies associated with the headache?

14. Are there any warning signs BEFORE the headache begins?

_____Paleness

_____Mood swings (either high or low)

_____Irritability

_____Dizziness

_____Tired, sleepy, or yawning

_____Increased appetite

_____Rings around the eyes

_____Hyperactivity

_____Craving sweets

_____Eye problems (like blurred vision, black spots, flashing lights, or double vision)

If there are any other warning signs, please describe them.

Neurology Headache Questionnaire

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