• HEADACHE HISTORY

    PATIENT INFORMATION
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  • Please review and answer all parts of each question with our staff. Provide specific details/notes.

    QUESTIONS
  •    


  • MEDICATION (NAME OF MEDICATION OR SUBSTANCE) WHAT DOSE? HOW OFTEN?
    Acetaminophen, Tyleno    
    Ibuprofen, Advil, Motrin, Nuprin, etc..    
    Naproxin, Aleve    
    Rx pain medication (                    )    
    Rx pain medication (                    )    
    Rx muscle relaxant (                    )    
    Rx anxiety medication (                   )    
    Rx depression medication (              )    
    Rx migraine medication (              )    
    Medication for sleeping (               )    
    Cafeine intake (                 )    
    Alcohol intake (                 )    
    THC, Medical Marijuana (               )    
    Other: (                  )    
  • I HEREBY ACKNOWLEDGE THAT THE ABOVE INFORMATION BEST DESCRIBES THE TREATMENTS AND MEDICATIONS I HAVE USED TO HELP ALLEVIATE MY HEADACHES/MIGRAINES/PAIN

     

     

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  • HEAD HEALTH HISTORY

    PATIENT INFORMATION
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  • CAUSES &COMPLICATIONS


  • 12. Problems with sleep?

  • 13. Do you experience pain in


  • IMPACT ON DAILY LIVING ACTIVITIES

  • 20. Because of pain, headaches or migraines, in the last month:

    # Of days you could not go to school: .....................

    # Of days you did reduced amount of work: ..................

    # Of days you could not do usual household work/parenting: ....................

    # Of days you missed family or social functions: ....................


  • 22. How many days per month are you:

    Pain Free? ...............

    Headache Free? ...............

  • Should be Empty: