Migraine Questionnaire

Name:
Age:
Date of Birth:
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Handedness:
Occupation:
Disability start date (if applicable):
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Cause of disability ie; headaches, other:
Marital Status:
Name of Third Party Medical Insurer and details:
Existing and Past Medical Conditions (Please check/list all that apply):
Other:
Surgeries, please list dates:
Current Medications (Include dosages and # of times used per day):
Drug Allergies (list name of drug and reaction):
How would you rate your mood in general?
How is your sleep?
Do you wake up with headache in the morning?
Do you eat breakfast?
Do you eat regular meals over the day?
Do you skip meals?
On average, how much caffeine do you consume daily? (# of drinks/day)
How Much alcohol do you drink on average?
How much do you smoke?
When approx. did you quit?
Do you do any regular exercise?
Is there a family history of headaches?
Which family member(s)?
Is there a family history of stroke / heart disease or neurological disease?
If Yes, Describe:
Headache Characteristics
Did you suffer from headaches when you were younger?
Comment:
When did your current headache problems begin?
Was there a precipitating event or trigger for your current headache problem?
Other Event:
What are the triggers for your headaches?
Other trigger:
How many headache-free days do you have per month?
On average, how often do you have a headache?
Are they increasing in frequency?
Headaches typically begin:
They usually begin in the:
How long before they reach maximal intensity?
Headaches usually last (with medication):
Headaches usually last (without medication):
How bad/intense are your headaches on your best day:
How bad/intense are your headaches on your worst day:
Which word best describes the quality of your headache:
Where do you experience the pain?
Other location:
When you have a headache do you have nausea or vomiting?
When you have a headache would you prefer to avoid:
Would you prefer to lie down when you get a headache?
What makes your headache better?
Other remedy:
Do you experience symptoms such as:
Please check off if you have been experiencing any of the following:
Please list any tests you may have completed. Please include the approximate date and facility the test was performed in. (ie; x rays, CT scan, MRI, VGH, Surrey memorial etc)
What are your hopes for your next visit?
Please check off the medications you have tried:
For the medications you have tried, please give more detail:
Extra notes:
Please type the text below: