Headache History Questionnaire
1. On a scale of 1-10, with "10" being the worst pain imaginable above the shoulders,




how many mornings per week do you wake with a "0" (zero)? _____
what's the average "number" you usually wake with? _____
what is your average headache pain level (1-10 scale) throughout the day? _____
what is the worst pain level you experience? _____
2. Mark a % of your waking time,



do you have some degree of headache? _____
do you have a "0" (zero) without taking medications? _____
do you have >15 days a month might you experience your worst pain? _____
3. I only notice my headache when





I can ignore my headache most of the time
I focus my attention on it.
My headache is painful, but I can continue what I am doing.
My headache makes concentration difficult, but I can perform demanding tasks.
My headache is so painful that I can’t do anything
4. What time of day do you usually experience your worst headaches? _____
5. How would you describe your pain? (Check all that apply)
o
o
o
o
o
o
o
o
o
Throbbing
Squeezing
Pressure
Dull
Sharp
Stabbing/shooting
crushing
Band-like
other
6. My head ache is related to (Check any/all conditions that apply)
o
o
o
o
o
o
o
o
direct sun or bright lights
noise
cold
heat
Rain and dampness
My menses
o
Before
o
During
o
After
When there is a problem you can’t resolve
When you have read for too long a period of time
o
o
o
o
o
o
o
o
When you are concentrating intensely on a task
When you physically over-exert yourself (exercise, sex, coughing, etc.)
When you haven’t been getting enough sleep
When you spread yourself too thin
Stress triggers
Emotional triggers
o
During an emotional upset
o
After you have an emotional upset
o
When you’re feeling overwhelmed
o
When you’re worried
o
When you’re feeling worn down
o
When you’re experiencing frustration and aggravation
Environmental triggers
Food triggers
7. Check the types of providers or alternative treatments you've seen for headache treatment
o
o
o
o
o
o
o
o
o
o
MD
Neurologist
ENT
Internist
Physical Therapist
Chiropractor
Dentist
Naturopath
Acupuncture
Energy work
8. What medical tests have been performed regarding your headaches?
o
o
o
o
CT scan
MRI Xray
Blood analysis
Other:
9. What types of treatments have you had for headaches? (Check all that apply)
o
o
o
o
o
o
o
o
o
o
o
o
Over-the-counter medications
Prescription medications
Injectable medications
Botox injections
Small amounts of caffeine
Rest in a quiet, dark room
Hot or cold compresses to your head or neck
Massage
Meditation
Relaxation training
Cognitive behavioral therapy
Biofeedback
On the diagrams, please mark: # 1:
Where you believe the headache originates
#2, 3, 4, etc.: Where the pain radiates to or around