PANDA - PRESENTING WITH HEADACHE

GENERAL INFORMATION
At what age did you start having any headaches, including “regular headaches”, “sinus headaches”, allergy headaches”?*
For girls/women: at what age did you have your first period?
Do you have headaches more than 15 days a month?*

NOYES
At what age did your headache become more frequent than 15 days a month? *
Do you have daily headaches?*

NOYES
At what age did your headache become daily?*
How many meals do you eat per day?*

How much of each liquid do you drink per day, approximately? *

On school/work days, what time do you go to bed?*

Hour Minutes

AM/PM Option
On school/work days, what time do you wake up?*

Hour Minutes

AM/PM Option
On NON-school/NON-work days, what time do you go to bed?*

Hour Minutes

AM/PM Option
On NON-school/NON-work days, what time do you wake up?*

Hour Minutes

AM/PM Option

HEADACHES
Where does your head hurt during a headache?*
What does your pain feel like?*
How long does your headache typically last if untreated?*
When you go to bed at night, do you ever wake up the following day with the headache still present?*

NOYES
How many days in a row did your longest headache last?
Does your headache ever limit you from being able to go to school/work/events?*

NOYES
Approximately how many times per month does this happen?
Of the remaining headaches each month (those with which you can still go to school/work/events), how many per month are severe?*
Of the remaining headaches each month (those with which you can still go to school/work/events), how many per month are tolerable and you can remain relatively functional?*
How many days per month do you use pain medications?*

OTHER SYMPTOMS WITH YOUR HEADACHE: (Check any of the symptoms below that you may experience with your headache.)*

	YES	NO
Worsening of headache by doing routine daily activities (is it better to sit/lay down and relax)?
Worsening of headache when coughing?
Worsening of headache when laughing?
Worsening of headache when lifting heavy objects?
Worsening of headache when straining to have a bowel movement?
Irritability when you have a headache?
Wanting to “shut down” or be left alone to do nothing during your headache?
Better to be in a "not too bright" room when you have a headache?
Better to be in a "not too loud" environment when you have a headache?
Bothered by strong smells when you have a headache?
Better to avoid being in a hot environment (like outside during the summer) when you have a headache?
Painful to touch your head while having a headache?
Prefer not to eat/want to avoid food when you have a headache?
Nausea when you have a headache?
Vomiting when you have a headache?
Abdominal pain when you have a headache?
Diarrhea when you have a headache?
Dizziness when you have a headache?
If dizziness occurs, is it worse upon standing?
Experience fogginess/difficulty concentrating?
Experience complete confusion?
Body collapses or you pass out?
Teary eye on side of headache ONLY?
Droopy eyelid on side of headache ONLY?
Stuffy nose on side of headache ONLY?
Runny nose on side of headache ONLY?
Fullness/pressure in your ear on side of headache ONLY?
Ringing in your ear on side of headache ONLY?
Sweating of your face on side of headache ONLY?
Puffiness of your face on side of headache ONLY?

Do you experience a change in your vision? if yes, please describe.*
Do you experience any other symptoms? If yes, please describe.*
What do you do to help your headache?*

drink plenty of fluidsdrink caffeinesleep/resttake my pain medicinesOther
Things that can bring on your headache?*

stress or anxietyexercisefatiguelack of sleepdehydrationhungerweather changesOther

Did you have any of the following events in your childhood/teenage years?*

	NO	YES	If Yes, at what age(s)?
Colic, as an infant?
As toddler, sudden repeated episodes of neck spasms?
Episodes during which your earlobe suddenly turns red AND painful?
Repeated episodes of sudden vertigo, with no trigger; if yes, from what age to what age?
Repeated episodes of vomiting for no reason; if yes, from what age to what age?
Repeated episodes of abdominal pain for no reason; if yes, from what age to what age?
Repeated episodes of nose bleeds for no reason; if yes, from what age to what age?
Bedwetting beyond the normal age; if yes, until what age?
Teeth clenching or grinding; if yes, from what age to what age?
Growing pains; if yes, from what age to what age?
Motion sickness?

Have you had any of the following procedures?*

Does anyone in your family have a history of any of the following:*