Headache Questionnaire

Patient Name:	Date of Birth:
Diagnosis	Today's Date:

Headache Questionnaire

Directions: Please circle yes to answer any questions that seem to pertain to your headaches. Skip the question if the answer is no.

	M	TT	C	O
1 . Did this same headache ever occur before?	Yes
2 . Do you have more than one type of headache?	Yes
3 . Do your headaches usually occur during daytime hours?	Yes
4 . Does your mother, father, siblings, children or any blood relative have similar headaches? (Answer NA if adopted)	Yes
5 . Do you have any changes in vision (flashing lights, blurred vision, or spots) before or during a headache?	Yes
6 . Does your headache pain throb or pound?	Yes
7 . Do your headaches occur during weekends and holidays?	Yes
8 . Do alcoholic drinks cause or aggravate your headaches?	Yes
9 . Does chocolate, cheese, milk, nuts, Chinese food, or any food cause or worsen your headache?	Yes
10 . Have you noticed any paralysis, muscle weakness, numbness, swallowing Problems or speech changes during your headaches?	Yes
11 . Would you describe your headache as moderate to severe in intensity?	Yes
12 . Does your headache ever require you to lie down?	Yes
13 . Do you prefer a dark, quiet room when you have a headache?	Yes
14 . Do you ever miss work (or school) because of headache?	Yes
15 . Do you see zigzag lines before a headache?	Yes
16 . Does your headache last between 1 to 3 days?	Yes
17 . Is your headache unresponsive to plain aspirin or Tylenol?	Yes
18 . Do bright lights or sunshine cause your bad headaches?	Yes
19 . Does a change in barometric pressure, or storms, ever trigger your headache?	Yes
20 . Does a change in your sleep schedule trigger your headaches?	Yes
21 . Does your headache pain feel as if your heart is beating in your head?	Yes
22 . Did your headaches begin in adolescence or early adulthood?	Yes
23 . Do you ever feel tired prior to a headache starting?	Yes

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