Headache intake form

Cape Regional Physicians Associates 11 Village Dr Patient Name_______________________ Date__________ Headache History
DO YOU HAVE MORE THAN ONE HEADACHE TYPE? □ yes □ no
***If yes, please use one history sheet for each. ***

1. ONSET OF FIRST HEADACHE:

I was: □ younger than 20 □ 20-30 □ 30-50 □ over 50 years old
2. PRECIPITATING EVENT (trigger of first headache):
□ None known □ injury
□ Menarche (first period) □ pregnancy
□ Other: ________________________________________________________

3. FREQUENCY
They occur: ____ times each □ day □ week □ month
Are they increasing? □ yes □ no
□ Weekdays □ Weekends □ Vacation
□ spring □ summer □ fall □ winter
□ No relation
4. ONSET OF EACH HEADACHE: □ gradual □ sudden □ varies
Onset most frequent: □ morning □ afternoon □ evening □ night

5. DURATION:
Lasts: ______ □ hours □ days with medication
______ □ hours □ days without medication
6. FREE OF HEADACHE from: _____________ to _______________ □ never free
If never free, when was the last time you went 24 hours without a headache?____________________
Cape Regional Physicians Associates 11 Village Dr Patient Name_______________________ Date__________
7. INTENSITY:
With medication: □ mild □ moderate □ severe □ incapacitating
Without medication: □ mild □ moderate □ severe □ incapacitating
(Continued)

8. HEADACHES EFFECT ON ABILITY TO FUNCTION:
□ able to function normally
□ ability to function slightly decreased
□ ability to function severely decreased
□ totally bedridden

9. LOCATION:
Starts □ left side □ right side □ either side □ both sides □ behind eye(s)
□ neck/back of head □ Other: __________________________________
10. PAIN TYPE:

□ throbbing □ achy □ pressure □ stabbing □ shooting □ tight
□ dull □ burning □ searing □ Other: __________________________________
11. HORMONAL:
Your headaches are affected by: □ your menstrual cycle □ pregnancy
How? ____________________________________________________________________________
12. HEADACHES CAN BE BROUGHT ON BY:
□ foods □ fatigue □ physical exertion □ stress □ weather changes
□ hunger □ lack of sleep □ menstruation □ loud sounds □ high altitude
□ alcohol □ too much sleep □ coughing □ bright lights □ loud sounds
□ medications□ sex/orgasm □ chewing or talking □ odors
□ Other: _____________________________________________________________________________
13. WARNINGS THAT A HEADACHE IS COMING:
□ light flashes □ numbness □ upset stomach
□ zigzag lines □ dizziness □ weakness
□ blindness □ lightheadedness
□ Other: _____________________________________________________________________________
Cape Regional Physicians Associates 11 Village Dr Patient Name_______________________ Date__________
14. ASSOCIATED SYMPTOMS:
□ nausea/ vomiting □ one eye tears □ sore or stiff neck □ ringing in ears
□ sensitive to: □ both eye tears □ lightheaded/dizzy □ increased urination
□ light □ diarrhea □ numbness/ tingling □ concentration/memory
□ sounds □ constipation □ change in sexual interest □ odors
□ odors □ fatigue or weakness □ increased appetite □ blurred vision
□ runny or stuffy nose □ insomnia □ decreased appetite
□ double vision
□ anxiety, tension or irritability □ Other: _______________________________________________
(Continued)
15. DURING A HEADACHE, YOU ARE MORE COMFORTABLE:
□ when lying down □ with massage or pressure on scalp □ when pacing
□ in a dark , quiet room □ with hot or cold compress (circle one) □ chewing or talking
□ Other: _____________________________________________________________________________
16. PREVIOUS TESTING (Please give date & results):
□ MRI: ________________________ □ cervical spine films: _____________________
□ CAT scan: ____________________ □ sinus X-rays: ___________________________
□ EEG: ________________________ □ MRA/MRV: ___________________________
□ Other: ______________________________________________________________________

17. PREVIOUS EVALUATIONS (Please give name, date & results):
□ neurologist: ________________________________________________________________________
□ headache specialist: _________________________________________________________________
□ internist: ___________________________________________________________________________
□ ear, nose & throat specialist: ___________________________________________________________
□ dental evaluation: ____________________________________________________________________
□ eye exam: __________________________________________________________________________
□ psychological testing: ________________________________________________________________
18. PREVIOUS NON-MEDICAL TREATMENTS & EVALUATIONS:
□ biofeedback/relaxation/self hypnosis □ physical therapy
□ chiropractor □ nutritional counseling
Cape Regional Physicians Associates 11 Village Dr Patient Name_______________________ Date__________ □ acupuncture/ acupressure □ allergy testing
□ Other: _____________________________________________________________________________
19. ARE YOU CURRENTLY TAKING MEDICATION or HAVE YOU PREVIOUSLY TAKEN
MEDICATION FOR HEADACHE? □ yes □ no
***If yes, please complete Medication History on the back. ***

20. WITH CURRENT MEDICATION, HOW QUICKLY DO YOU FEEL ADEQUATE RELIEF?
□ within 2 hours □ in more than 2 hours
□ relief is never adequate □ not currently taking medication

Patient Name:
__________________
Date: __________
Please circle all previous headache medications and indicate next to the drug name add h for helpful (long or short
term) and u for not helpful
Prophalactics
Prophalactics
Abortives
Narcotics
Cape Regional Physicians Associates 11 Village Dr Patient Name_______________________ Date__________ Muscle relaxants
Anti-anxiety

Source: http://caperegionalphysicians.com/docs/Headache%20intake%20form.pdf?pid=58