Headache Log www.ourfamilydoctors.net Name
Headache Log
Name:
Date
Time of onset Time headache ended
Activity prior to headache
Location of headache ie: front, back
Pain scale 0-10 10 as worst pain
June 3, 2009 2 : 00 p.m.
9 : 15 p.m.
Watching T.V. EXAMPLE
Top of head
8
:
:
:
:
:
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:
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:
:
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:
Medication taken and time
Effectiveness of medication Triggers ie: stress, alcohol, bright light Associated symptoms ie: nausea, dizziness
Ibuprofen 600 mg at 2:10 p.m.
Did not help
Finished a large meal
Blurred vision, loud noises hurt, nausea
Physician Instruction:
Return for follow-up office visit in:
1 week
2 weeks
1 month
3 months
PLEASE BRING THIS LOG WITH YOU TO YOUR NEXT FOLLOW-UP OFFICE VISIT
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