Medical History Form

HEADACHE HISTORY

PATIENT INFORMATION
NAME
DATE TODAY

Month Day Year
Date
AGE
SEX

MALE FEMALE
TELEPHONE
Please review and answer all parts of each question with our staff. Provide specific details/notes.

QUESTIONS
1. Have you been diagnosed with any of the following?

Migraine Chronic Daily Headache Tension Headache Cluster Headache Medication Overuse Headache
2. What sets off or triggers your headaches?
3. What test have you had to help diagnose your headaches?

MRI CT Scan Blood Tests Hormone Testing
4. Where are your headaches located?

Back Front Right Side Left Side

On a scale of 1-10, how painful are your headaches/migraines?

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Unbearable Pain

5. Describe the type of headache pain you feel most often:

Achy Throbbing Stabbing Type option 4
If Other, please specify
6. What other doctors have you seen for your pain, headaches, and/or migraines

GP / FAMILY DOCTOR / OB-GYN DENTIST (IF OTHER) NEUROLOGIST PSYCHIATRIST/PSYCHOLOGIST PHYSICAL THERAPIST CHIROPRACTOR EAR NOSE THROAT

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: ( )

8. Do you try non-medicating techniques for managing your pain or headaches?

Yes No
Yoga Breathing Exercises Cold Packs Massage Meditation Physical Therapy Hot Packs/ Hot Bath Acupuncture Exercise Other (please describe)
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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HEADACHE HISTORY