NeuroCare Center Pain Management Headache Assessment

To complete questionnaire, please check the box or fill in the blanks with the best answer. Patient History: Name: Birth date: Referring physician: Reason for visit: Past treatment: Location of clinic or center: Past testing: G MRI G MRA Where were these completed? G CT scan G EEG G Sleep study G Lab tests G headache clinic G pain management center G none Age: G Male G Female Date:

Primary physician:

PLEASE BRING ALL REPORTS OF TREATMENT OR TESTING WITH YOU TO THE FIRST VISIT. Headache History: Do you have more than one headache type: If yes, briefly describe the different headaches here: First headache type: Second headache type: Are you ever HEADACHE FREE? Onset of first headache: G Yes G No I was _______________ years old. G Yes G No

started _______________ years ago

Precipitating event (what provoked your first headache?) G none known G menarche (first period) G injury: ___________________________________ G pregnancy G other: ________________________________________________________________ Current pattern: Time of day: G sudden G morning G rapid G evening G gradual G night G varies G awaken from sleep _____ per year G varies

G afternoon

Frequency (number of attacks): Fill in the number. _____ per day _____ per week _____ per month G continuous G lifetime attacks Are they increasing in frequency? G Yes G No _____ days _____ days

Duration (how long do they last?) Fill in the number. with medication _____ minutes _____ hours without medication _____ minutes _____ hours How often do they recur within 24 hours:

with medication _____

without medication ______

Provoking factors (things that bring on a headache) Food/beverage: G fasting G chocolate G caffeine G nitrates G MSG G alcoholic beverages - what ones in particular? G other: Physical exertion: Hormonal menses: Stress: Environmental: G coughing G before G work G other: G allergies G other: G talking G during G home G chewing G after G exercise G pregnancy G sexual intercourse G menopause

G family G spouse G altitude G sunlight

G weather changes G too much sleep G 1-3 G 3-5 G 5-7

Sleep: G lack of sleep How many hours of sleep do you average? Other triggers:

G change in wake/sleep G7-8 G 8-10

NeuroCare Center Pain Management Headache Assessment

What makes your headache worse? How do your headaches affect your ability to function? Write in the number of days missed: work productivity school social/family activities __________ days/month missed __________ days/month missed __________ days/month missed

Severity how bad is the pain on a scale of 0-10 where 0 is no pain and 10 is the most unbearable (circle the number) today 0-----1-----2-----3-----4-----5-----6-----7-----8-----9-----10 best day 0-----1-----2-----3-----4-----5-----6-----7-----8-----9-----10 worst day 0-----1-----2-----3-----4-----5-----6-----7-----8-----9-----10

Please place an X on the drawing to show the location(s) of your pain.

What symptoms do you experience with your headache? G nausea G diarrhea G vomiting G sensitivity to sound G dizziness G stuffy/runny nose G red/teary eyes G sensitivity to light G vision changes G numbness/tingling G ringing in the ears G sensitivity to smell G anorexia (loss of appetite) Check any of the following that you have used to reduce the frequency of and duration of your headache: G biofeedback G acupuncture G occipital blocks G TENS G exercise G counseling G heat G ice G stress management G relaxation techniques G chiropractic treatments G pain management center G cervical epidural injections G alternative medicine clinic Do you have allergies to: G dyes G iodine G tyramine G latex G No G herbal remedies G massage therapy

Do you experience fatigue or a drained feeling following the resolution of your headache? G Yes Social History: G single G married If married, fill in your spouses S pouses general health status: Who resides in your home? Live with: Do you smoke? Do you consume alcohol? If yes, what type and how often? Do you use illicit or recreational drugs? If yes, what kind and how often? Have you ever had a problem with drug or alcohol abuse? G Yes G No G Yes G Yes G No G No G Never smoked G widowed age: __________ G divorced G separated

occupation: _________________________

G live alone

G children at home

G Second-hand smoke

NeuroCare Center Pain Management Headache Assessment

What is your level of education? G less than high school - highest grade level completed: __________ G high school G some college G bachelors degree G associate/technical degree G advanced degree List your hobbies: __________________________________________________________________________________________ What is your occupation? Current employer: Previous employer: Are you working now? Describe your work: G Yes G No If no, last date worked: ____________________ G disabled

How many hours per day do you spend: sitting __________ lifting __________ walking __________ standing __________ driving __________

how many pounds? __________ dont like -----1-----2-----3-----4-----5-----love low-----1-----2-----3-----4-----5-----high

Please rate how well you like your job (circle) Rate your level of anger (circle) Medical History: General health: G excellent G good

G fair

G poor G asthma G ulcers/stomach problems G kidney/renal disease G infectious disease G gynecologic problems G psychiatric problems G hospitalizations G other:

Have you had any of the following medical problems? G diabetes G arthritis G hypertension G neck/spine problems G heart disease G skin problems G stroke/TIA G cancer G seizure/epilepsy G hepatitis/liver disease G head injury G phlebitis G ear, nose, throat problems G thyroid disease G dental problems G lung disease

If you have been hospitalized or had surgery, please list the date, reason and hospital:

Current medications:

NeuroCare Center Pain Management Headache Assessment

Past medications taken for headaches:

Vital Signs (for medical staff use only) Pulse: Height: Comments: Blood Pressure: Weight: Respirations:

Medication Questionnaire: Please mark any of the following medications that you have taken in the past: NSAIDS: G Motrin G Advil G Ibuprofen G Toradol G Naproxen Sodium G Excedrin Migraine G Indocin G Diclofenac Analgesics: G Acetominophen G Tylenol G Midrin G Florcet G Tylenol #3 G Vicodin G Demerol G Darvocet G Darvon G Percocet G Talwin G Oxycodone G Fiorinal Antidepressants:: Triptans: Calcium Channel Blockers: G Zoloft G Imitrex G Verapamil G Paxil G Zomig G Diltiazem G Pamelor G Acert G Nimodipin G Nardil G Maxalt G Phenelzine G Amerge Anticonvulsants: G Elavil G Depakote G Trazodone Beta Blockers: G Depakote ER G Inderal G Neurontin Antiemetics: G Nadolol G Gabitril G Compazine G Atenolol G Topamax G Phenergan G Metroprolol G Biocardren Other: G Zofran G Tigan G Topol XL G Cyroheptadine G Inderal LA G Sansert G Estradiol G Feverfew G Vitamin B12 G D.H.E.A G Propofol

Please list any medications you take that are not listed above:

Thank you for providing this very important information. PLEASE READ THE FOLLOWING: This questionnaire will become part of your medical record. Any false information or omissions may lead to termination of treatment from NeuroCare Center, Inc. Complications and side effects due to falsifications or omissions are the responsibility of the patient. I verify that the above information is accurate and complete.

Signature of Patient _________________________________________________

Date _____________________________