HEADACHE QUESTIONNAIRE
The answers to these questions will help us determine whether your condition is disabling within the meaning of the law. Please fully explain your answers wherever possible by giving descriptions and examples.
CLAIMANT NAME:
*
SSN:
*
Date:
*
/
Month
/
Day
Year
Email:
*
You will receive confirmation email at this address.
1) When did you start having headaches? (Approximate date)
*
0/525
2) When was your last headache?
*
0/200
3) What causes your headaches?
*
0/525
4) Describe a typical headache.
Rows
Typical Headache
a) Type (for example migraine, sinus, cluster)
b) Location (for example, front, temple, middle, side, back)
c) Symptoms (for example, nausea, vomiting, blurred vision)
5) How often do you get headaches? (for example, daily, weekly, monthly)
*
0/425
6) How long does a typical headache last?
*
0/425
7) Describe any limitations in your activities during a typical headache and how long these limitations last (for example, darkened room, lying without moving, sleep disturbance).
*
0/800
8) List current headache medication(s).
*
Rows
MEDICATION NAME, DOSAGE, AND FREQUENCY
DATE STARTED
IF PRESCRIBED, NAME OF HEALTH CARE PROFESSIONAL
SIDE EFFECT(S)
1
2
3
9) Have you visited an emergency room for treatment to relieve a headache? If so, when and where?
*
0/525
10) Do you use any other treatments to relieve your headaches? If so, describe.
*
0/525
11) Have you ever seen any health care professionals for your headaches since you filed your claim.
*
Yes
No
If you have seen any health care professionals for your headaches since you filed your claim, complete the chart below.
*
Rows
NAME OF HEALTH CARE PROFESSIONAL
ADDRESS AND PHONE NUMBER
DATE OF LAST VISIT AND NEXT SCHEDULED APPOINTMENT (IF ANY)
1
2
3
4
Name of person completing this form:
*
(Please print)
Date:
*
-
Month
-
Day
Year
Date
Telephone No.:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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