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jefferson headache center

Name: ________________________________________ Date: ________________________ JEFFERSON HEADACHE CENTER

Patient History

Name: _______________________________ D.OB: ____________ Age: _______ Phone: (H)_____________________ (W)_____________________ (C)____________________ Do you have more than one headache type?
1. Are you ever headache free:
Name: ________________________________________ Date: ________________________ 4. Frequency: (the number of attacks)
Lasts ___ mins ___hours ___days without medication How often does recure within 24hrs? ___
6. Severity: (how bad is the pain on a scale of 0 to 10; 0 is no pain, 10 is the worse)
Lowest and highest level of pain for this headache type: Low ________ High________
Usual severity of this headache type: ________
Character:

8. Activity that worsens headache: Headache disability during or after an attack:

Name: ________________________________________ Date: ________________________ 9. Associated Symptoms:


10. Aura: Visual (Do you have these symptoms before your headache begins?)
The visual symptoms last a total of: ______________. If you have more than one symptom, do they happen: Do you have a visual aura without headache pain? If you have more than one symptom, do they happen: Do you experience sensory aura without headache pain? Name: ________________________________________ Date: ________________________
12. Premonitory Symptoms (you experience one or more of these symptoms before onset of
headache):


13. Provoking Factors:
(things that bring on a headache)
Food/beverage:
Physical exertion:
Hormonal:
Enviormental:
Name: ________________________________________ Date: ________________________ Headache History #2
1. Describe your second headache type: ____________________________________________
Onset of Second Headache:
Headaches started ____ years ago. I was ____ years old.
2. Precipitating Events
(what provoked your first headache):
Lasts ___ mins ___hours ___days without medication How often does recure within 24hrs? ___
5. Severity:
(how bad is the pain on a scale of 0 to 10; 0 is no pain, 10 is the worse)
Lowest and highest level of pain for this headache type: Low ________ High________
Usual severity of this headache type: ________
Name: ________________________________________ Date: ________________________ Character:

7. Activity that worsens headache: Headache disability during or after an attack:


8. Associated Symptoms:


9. Aura: Visual
(Do you have these symptoms before your headache begins?)
The visual symptoms last a total of: ______________. If you have more than one symptom, do they happen: Do you have a visual aura without headache pain? Name: ________________________________________ Date: ________________________ 10. Aura: Sensory

If you have more than one symptom, do they happen: Do you experience sensory aura without headache pain?
12. Provoking Factors: (things that bring on a headache)
Food/beverage:
Physical exertion:
Hormonal:
Environmental:
Name: ________________________________________ Date: ________________________ 13. Relieving Factors:


Quality of Life Review:

1. My appetite lately is:
Name: ________________________________________ Date: ________________________ Previous Treatment and Testing:
1. Previous treatments:
(please give name of provider, date, type of treatment and if it helped)

____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________
2. Previous Test:
(Please give date and results)
Name: ________________________________________ Date: ________________________ Previous Headache Medication: (please check any medication that you have taken for your headache and write
the largest does you tried next to it)
Preventives:
[ ]Celexa
[ ] Imipramine [ ]Pamelor (nortriptyline) [ ]Other trycyclic [ ]Inderal (propranolol) [ ]Tenormin (atenolol) [ ]Cardizem (diltiazem) [ ]Procardia (nifedipine) [ ]Nonsteroidal antiinflammatory drug(s) [ ]Other [ ]Coenzyme Q [ ]Vitamin B2 (Riboflavin)
Abortives:
[ ]DHE
Name: ________________________________________ Date: ________________________ Abortives Con’t:
[ ]Advil (ibuprofen)
[ ]Anaprox (naproxen sodium) [ ]Cataflam [ ]Relafen (ketoprofen) [ ]Voltaren (diclofenac) [ ]Vioxx [ ]Benadryl (diphenhydramine) [ ]Compazine (prochlorperazine) Medication List
Current medicines. Headache patients skip to headache history. Please list medication and daily dosage.
Please list ALL medications currently taken; include over-the-counter medications and vitamins
Medication
Side Effects
Medication
Side Effects
PREVIOUS Headache Medications
Medication
Side Effects
Medication
Side Effects
Name: ________________________________________ Date: ________________________ Allergies:
1. Allergies:
2. Have you hadn any of the following medical problems? 3. Have you ever been hospitalized or had surgery? (list reason, date, hospital)
4. Menstural History:
If not montly, every: ______________________ Reason for menopause: ___________________ symptoms:___________________________________________________________ 5. Obstetrical History:

Current method of contraception: ______________________________ Name: ________________________________________ Date: ________________________ History:
If disabled, why? _____________________________ Type of work: ________________________________ 7. Risk Factors:
Year began: _________ Year stopped: _______________ __________________________________________________________________
If alive, give age & current health status (good/fair/poor).If deceased, give age & cause of death.
Father_________________________________ Spouse _________________________________
Mother ________________________________ Children _______________________________
Siblings _______________________________________________________________________

Name: ________________________________________ Date: ________________________ Review of Systems:

11. Have you been having any of the following symptoms not associated with your headache?


You can use this space to describe anything you feel is important that was not covered in
this questionnaire.

Source: http://www.jefferson.edu/content/dam/tju/jmc/files/neurology/JeffersonHeadacheCenterInformationForm.pdf

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