Headache Assessment Questionnaire Headache Assessment Your Full Name * Date of Birth * Your GP * Please choose from listDr CashDr WallsDr BoydDr CalvertDr MacSorleyDr CarswellDr DuffyDr DickieDr MaysonANP Claire HillDr GilhespyDr Popham 1. Did the headaches start after an: * Accident Illness Infection OtherOther 2. How long have you had these headaches? * 3. Are the headaches constant or do they come and go? * Constant Come and go 4. How often do the headaches occur? * Daily Weekly Monthly Variable OtherOther 5. Do the headaches occur at a certain time of day? * Morning Afternoon Night OtherOther 6. Are the headaches becoming stronger, lasting longer or occurring more frequently? * 7. Do the headaches ever wake you up when you're sleeping? * Yes No 8. Does rest or sleep relieve the headache? * Yes No 9. Do your headaches stop you from doing things? (like playing, watching TV, going outside or doing housework) * 10. Have you ever missed work or school because of a headache? * Yes No 11. Is the headache pain intense when it starts, or does it start out small and build up? * Starts as intense Starts small and builds 12. Are nasal congestion, sinusitis or allergies associated with the headache? * 13. Please check all of the things that bring on the headaches: * Odours (perfume, cigarettes) Hunger (missing meals) Exercise or playing Too much sleep (sleeping in) Too little sleep (staying up late) Riding in a car Fatigue Loud noises Ice cream Bright lights Sunshine Hot weather School/Work Anxiety or stress Family problems Menstrual cycles (women only) Birth control pills Alcohol Medications (if so, which ones?)Medications (if so, which ones?) Certain Foods (if so, which ones?)Certain Foods (if so, which ones?) Other (please specify)Other (please specify) Nothing 14. Are there any warning signs BEFORE the headache begins? * Paleness Dizziness Rings around the eyes Eye problems (like blurred vision, black spots, flashing lights or double vision) Mood swings (either high or low) Tired, sleepy or yawning Hyperactivity Irritability Increased appetite Craving sweets Other (please specify)Other (please specify) No warnings 15. Where is the headache located? * Left side Right side Neck Forehead Temples Back of the head All around the head Top of the head Other (please describe)Other (please describe) 16. What does the pain feel like? * Throbbing or pounding (like a hammer) Tightness (like a rubber band wrapped around the head) Dull Aching Exploding Pressure Sharp Describe in your own wordsDescribe in your own words 17. Are there any other symptoms when you have a headache? * Nausea Vomiting Stomach pains Confusion Weakness in the arms or legs Numbness in the arms or legs Other (please describe)Other (please describe) 18. Who else in the family has had headaches, migraines, sick headaches, motion sickness, “brain freeze” from eating ice cream or had trouble taking Birth Control Pills because of headaches? * 19. Describe any stresses in the last year (such as separation, divorce, job change, moves, death in the family or poor grades) * 20. Have you been treated in the last for headaches? If so, who treated you and when? * 21. What medication or treatments have you tried? (e.g. glasses, allergy medication, chiropractor, herbal medicines, ibuprofen, paracetamol, prescription medication) * 22. Have you had any of the following tests? (tick all that apply) * CT scan MRI Sinus x-ray Spinal tap Eye Exam Dental exam Allergy tests Blood tests OtherOther None of these 23. Do you have any questions about your headaches? What worries you the most? What tests, medicines or therapies do you want to know about? * CAPTCHA Submit Δ Headache Diary If your GP has asked you to complete the headache diary as well, you can access them here: PDF | Word Once complete you can either hand in at reception, or use our file upload form.
