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Patient name:Date of Birth:I have ________________ headaches per: (circle) week monthThe longest time without any headache is:On average, the headaches last ____________ minutes hours daysThe headaches started ______________ years ago. YesNoI wake with a headache.YesNoI had car sickness or motion sickness as a child. YesNoThe headaches have changed since they first started. YesNoFor women, the headaches are related to your menstrual cycle. YesNoThere is a non-painful warning that a headache will start soon. YesNoThis is a visual change, e.g. black spots/jagged lines/heat waves, flashing lights.YesNoThere is a funny feeling e.g. butterflies in the stomach, bad taste or smell.Other:The pain starts:Then spreads:The pain is:I have:Left LeftSharpNauseaRightRightDullVomitingFrontFrontThrobbingLight makes it worseBackBackConstantSound makes it worseTempleTempleSmell makes it worseShoulderShoulderActivity makes it worseNeckNeckEverywhereEverywhereOn a scale on 1-10, where 10 is the worst pain imaginable, the average pain is _________ and the maximum pain is __________.My sinuses hurt during a headacheYesNoLeftRightMy eye(s) run during a headacheYesNoLeftRightMy nose runs during a HeadacheYesNoLeftRightMy eye(s) turn red during a headacheYesNoLeftRightA part of my body feels numb or weak during a headacheYesNoDescribe:Members of my family who have headaches:Medications that have helped the headache? (Include dates, and why stopped)This information provided on this questionnaire is correct to the best of my knowledge._________________________________________ _______________Signature Date/Time ................
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