Headache Follow-Up Form - Appointment Date:
Dr. Olinka Hrebicek, Neurology
Headache Follow-Up Form
Personal Information
Full Name
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Daytime Phone Number
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Email
*
example@example.com
Primary Care Provider
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Preferred pharmacy name and location
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Age
*
Height
*
Weight
*
Current Neurological Concerns
Neurological Concerns: Why are you here today?
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Have you had any new diagnoses since your last visit? If yes, please note:
Has there been a change in your medications since your last visit? If yes, please note:
Do you have any medication allergies?
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Yes (Please list below)
No
Medication allergies:
Do you have extended benefit coverage?
No
Yes
Since your last visit have you experienced problems with:
Balance
Bathing
Bladder
Bowel
Climbing/descending stairs
Coordination
Dressing
Fatigue
Feeding
Grooming
Hearing
Memory (short/long term)
Mobility
Mood and thought disturbances
Muscle spasticity/stiffness
Pain
Sexual function
Speech
Transfers
Vision
Relapse (appearance of new or worsening of old symptoms lasting at least 24 hours)
Other
For those patients on injectable drugs:
Missed injection
Problems at injection site
Side-effects
Other
The Migraine Disability Assessment Test
1) On how many days in the last 3 months did you miss work or school because of your headaches?
2) How many days in the last 3 months was your productivity at work or school reduced by half or more because of your headaches? (Do not include days you counted in question 1 where you missed work or school?)
3) On how many days in the last 3 months did you not do household work (such as housework, home repairs and maintenance, shopping, caring for children and relatives) because of your headaches?
4) How many days in the last 3 months was your productivity in household work reduced by half or more because of your headaches? (Do not include days you counted in question 3 where you did not do household work.)
5) On how many days in the last 3 months did you miss family, social or leisure activities because of your headaches?
MIDAS Score
Rows
#1
#2
#3
#4
#5
TOTAL DAYS
Score
A) On how many days in the last 3 months did you have a headache? (If a headache lasted more than one day, count each day.)
*
B) On a scale of 0-10, on average how painful were these headaches? (where 0=no pain at all and 10= pain as bad as it can be.)
Have you had new or different headaches in the past 6 months?
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Yes
No
Do you currently receive Botox
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No
Yes (Who administers your treatment?)
HIT-6 Headache Impact Test
Rows
Never
Rarely
Sometimes
Often
Always
When you have headaches, how often is the pain severe?
How often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities?
When you have a headache, how often do you wish you could lie down?
In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches?
In the past 4 weeks, how often have you felt fed up or irritated because of your headaches?
In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities?
Hit-6 Score
Rows
Never (6)
Rarely (8)
Sometimes (10)
Often (11)
Always (13)
TOTAL
Service Quality
Interactions between Dr. Hrebicek, office staff and patients should always be professional, respectful and courteous. If I am unable to meet this expectation, I understand that it may affect my ability to continue as a patient in this practice.
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I understand
I understand that there may be a fee for certain services performed by the doctor. (Ie. Completing insurance forms or other tasks, according to the Doctors of BC Fees for Uninsured Services.)
*
I understand
Submit
Should be Empty: