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Walter Reed National Military Medical Center

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Walter Reed National Military Medical Center > Apps > Neurology > HeadacheQuestions
 

Neurology Headache Questions

 
Patient Name:
Email:
Date of birth (mm/dd/yyyy):

On what part of the head do the headaches start (check all that apply)?
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After the headache starts - Does it usually
Please explain:
How would you describe the pain (check all that apply)?
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If other, please explain:
Describe the degree of pain on a scale of 1-10 (1=slight, 5=beginning to interfere with
activity, 10=worst imaginable) for your average headache?
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Describe the degree of pain on a scale of 1-10 (1=slight, 5=beginning to interfere with
activity, 10=worst imaginable) for your worst headache?
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Do your headaches interfere or prevent normal activities - work etc.?
How long ago did the current headaches start?
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How old were you when any headache started?
How long does the headache usually last?
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How often does the headache occur?
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Does the headache awaken you from sleep?
Is the headache getting...


Do any of the following symptoms occur either before, during or after the headache?
General:
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Face/Scalp:
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Neck:
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Hands and/or feet:
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Eyes:
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Arms/legs:
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Indicate if any of the following factors have brought or worsen your headache:
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Do any blood relatives have severe headaches?
If yes, Who and Diagnosis:
Which of the following makes the headache better?
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Personal History
Cig (#/day/#yrs):  Alcohol (oz./day):  Coffee (cups/day):
Are you or have been:
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Previous professional treatment of headache?
Previous x-ray or other investigations of headache?
If yes, describe:
Previous medications for headache?
If yes, Name/dosage:
Other current medications? Please list (include over-the-counter drugs):
Drug Allergies:

Comments: