• Headache Assessment

    Answer the questions about your headache history, triggers, symptoms, and treatments across the pages.

  • Page 1

  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Months or years?
  • Have your headaches changed in the last six months?
  • Where are your headaches located?
  • Did you suffer from headaches when you were younger?
  • If so,
  • Was there a specific event that caused your current headache problem?
  • Specific event

  • Page 2

  • How often do you get severe headaches/migraines that make it difficult to function without treatment or medication?*
  • How often do you get other milder headaches?*
  • Are your headaches increasing in frequency?*
  • If so, describe frequency:
  • Headaches typically begin:*
  • Headaches usually begin in the:*
  • How bad are your headaches? With medication*
  • How bad are your headaches? Without medication*
  • Headaches prevent activities such as:
  • What does your headache pain typically feel like?

  • Page 3

  • Do any of the following bring on/trigger your headaches?*
  • How did you become aware of your triggers? (Please check all that apply and provide detail if necessary)
  • Do you experience any of the following before your headache begins?*

  • Page 4

  • Do you experience any of these symptoms during your headaches?
  • What other doctors have you seen or tests have you had for your pain, headaches and/or migraines?
  • Do you try non-medicating techniques for managing your headaches?
  • Techniques
  • Should be Empty: