Headache/Migraine Patient Intake Form
Date
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Month
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Day
Year
Date
Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
How old were you when you started having headaches?
How often do you have a mild-moderate headache?
How often do you have a severe headache/migraine?
How long do the severe headaches last?
Hours
One day
Two days
Three or more days
On a scale of 1-10, 10 being the worst, how severe are the headaches?
Best
1
2
3
4
5
6
7
8
9
Worst
10
1 is Best, 10 is Worst
Do you have some type of headache every day?
Yes
No
What does your headache typically feel like? (Check all that apply)
throbbing
pressure
sharp/Stabbing
tightness
burning
Other
What symptoms do you usually have during your typical headache/migraine (Check all that apply)
Nausea
Vomiting
Sensitivity to light
Sensitivity to sound
Pain on one side
Other
Have you experienced any of the following symptoms before a headache/migraine? (check all that apply)
Visual disturbances
Numbness
Difficulty talking
Other
Check any of the following if they play a role in your headaches or in producing an occasional headache
stress
after Stress is over
weather changes
foods
bright sunslight
sexual activity
lack of sleep
too much sleep
hormonal changes
menstrual cycle
exercise
exertion
missing a meal
different odors (e.g. cigarette smoke, perfume)
seasonal changes
Other
Have you had any imaging or testing for your headaches?
CT scan
MRI
Blood work
If you had imaging or testing, when and what did it show? Please bring discs with you.
How many times in the last year did you go to the ER because headaches/migraine?
Acute Treatments Tried
Analgesics/NSAIDs (acetaminophen, aspirin, ibuprofen, naproxen, etc)
Ergot alkaloid derivatives (ergotamine, dihydroergotamine)
Triptans (rizatriptan, sumatriptan, zolmitriptan, etc)
Prescription Pain Medications (oxycodone, hydrocodone, etc)
Butalbital containing medications (Fioricet, Fiorinal, Esgic, etc)
Anti-nausea medications (propchlorperazine, metoclopramide, ondansetron, etc)
Other
Please describe your results/tolerability of the acute agents tried
Preventative Treatments Tried
Antidepressants (amitriptyline, venlafaxine, etc)
Antiseizure medications (topiramate, valproic acid, etc)
Beta-blockers (propranolol, metoprolol, etc)
Calcium Channel Blockers (verapamil, amlodipine, etc)
Botox
Other
Please describe your results/tolerability of the preventative agents tried
Submit
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