Headache History Questionnaire printable pdf download

Headache History Questionnaire

Name:___________________ Date:___________

1. On a scale of 1-10, with "10" being the worst pain imaginable above the shoulders,

how many mornings per week do you wake with a "0" (zero)?

_____

2. On a scale of 1-10, what's the average "number" you usually wake with?

_____

3. What % of your waking time do you have some degree of headache?

_____

4. What % of your waking time do you have a "0" (zero) without taking medications?

_____

5. What is your average headache pain level (1-10 scale) throughout the day?

_____

6. On a scale of 1-10, what is the worst pain level you experience?

_____

7. What time of day do you usually experience your worst headaches?

_____

8. How many times per week (or month) might you experience your worst pain?

_____

9. Where does your pain seem to originate from?

___________________________________________________________________________

10. How would you describe your pain?

(examples: throbbing, squeezing, pressure, dull, stabbing, shooting, etc.)

___________________________________________________________________________

11. Please circle the types of health care providers you've seen for your headaches.

MD Neurologist ENT Internist Physical Therapist Chiropractor Dentist

Others: ____________________________________________________________________

12. What medical tests have been performed regarding your headaches?

CT scan MRI Xray Blood analysis Other: __________________________________

13. What types of procedures or treatments (including dental) have you had (for headaches)?

__________________________________________________________________________

14. What medication(s) do you now take to prevent your headaches?

__________________________________________________________________________

15. What medications have you tried to prevent your headaches?

___________________________________________________________________________

16. What Rx’ed or over-the-counter meds. do you take to relieve your headaches? (and how much)

_________________________________________________________________________

Below: Shade in the areas on your head/neck/shoulders to designate the location(s) of your headache:

Headache History Questionnaire