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Headache History Questionnaire:
Please print this form
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| 1. On a scale of 1-10, with
"10" being the worst pain imaginable above the shoulders, how many
mornings per week do you wake with a "0" (zero)? |
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| 2. On a scale of 1-10, what's the average "number" you usually wake with? | ____ |
| 3. What % of your waking time do you have some degree of headache? | ____ |
| 4. What % of your waking time do you have a "0" (zero) without taking medications? | ____ |
| 5. What is your average headache pain level (1-10 scale) throughout the day? | ____ |
| 6. On a scale of 1-10, what is the worst pain level you experience? | ____ |
| 7. What time of day do you usually experience your worst headaches? | ____ |
| 8. How many times per week (or month) might you experience your worst pain? | ____ |
| 9. Where does your pain seem to originate from? | |
| ___________________________________________________________________________ | |
| 10. How would you describe your pain? | |
| (examples: throbbing, squeezing, pressure, dull, stabbing, shooting, etc.) | |
| ___________________________________________________________________________ | |
| 11. Please circle the types of health care providers you've seen for your headaches. | |
| MD Neurologist ENT Internist Physical Therapist Chiropractor Dentist | |
| Others: _____________________________________________________ | |
| 12. What medical tests have been performed regarding your headaches? | |
| CT scan MRI Xray Blood analysis Other: ________________________ | |
| 13. What types of procedures
or treatments (including dental) have you had regarding your headaches? |
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| ___________________________________________________________________________ | |
| 14. What medication(s) do you now take to prevent your headaches? | |
| _________________________________________________________________ | |
| 15. What medications have you tried to prevent your headaches? | |
| _________________________________________________________________ | |
| 16. What prescription or over-the-counter medications do you take
to relieve you headaches? (and how much) |
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| _________________________________________________________________ | |
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