UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL
HEADACHE HISTORY FORM
NUTRITION FOR CHRONIC DAILY HEADACHE
NAME:
DATE OF BIRTH:
MEDICAL RECORD NUMBER:
SEX: Female Male
RACE:
African American
American Indian
Asian American
Caucasian
Hispanic
Name of your neurologist and city where his/her office is located:
Name of your family doctor and city where his/her office is located:
Other
YES
QUESTIONS
NO
EXPLANATION
(IF YES PUT DETAILS HERE)
Did you ever have headaches that put you in
bed or took you out of school or activities as a
child?
Did you ever see a doctor for childhood
headaches?
Ever been carsick?
Ever had head, neck, or jaw injury?
Ever lost consciousness for any reason?
Ever had a fall on your back or tailbone?
Ever had a motor vehicle accident?
Have you seen doctors other than your family
doctor about your headaches?
If you are female, have you ever had a
headache near your menstrual cycle?
If you are female, do you still have menstrual
periods?
If female, how old were you with your 1st
menstrual period?
If female, have you ever been pregnant?
If yes, when during your cycle?
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Age=
How many times?
How many children do you have living?
I first started having headaches at age:
Write age in years here
My most recent headaches started at age:
Write age in years here
Please circle the answer that seems best to each of the following questions:
In an average week I have about this many total headaches: Circle one number:
0
1
2
3
4
5
6
7
In an average week I have about this many SEVERE headaches: Circle one number:
0
1
2
3
4
5
6
7
If I counted all my headaches I had in a month, the number of days WITHOUT ANY headache
at all in a month would be: (CIRCLE ONE NUMBER THAT FITS YOU BEST )
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
My headaches are:
Aching
Throbbing/pounding
Pressure/squeezing
Stabbing
Shooting
My head hurts:
On one side
On both sides
In the front
In the back
All over
My headache, when severe, is worse with:
Smells
Moving my head
Foods
Lying down
Bright Light
Standing Up
Loud Noise
Walking the stairs
My headache usually lasts:
Less than 1 minute
13-24 hours
Less than one hour
25-48 hours
When I have a headache, I:
Keep doing what I was doing
Take a pill and keep doing what I was doing
Check the appropriate answer to the following
yes/no questions:
Do you get a warning that a headache is coming?
1-3 hours
More than 48 hours
YES
NO
4-12 hours
It never goes away
Have to lie down
EXPLANATION
Do you throw up with your headaches?
Does your neck hurt when you have a headache?
Do your eyes and/or nose run when you have a headache?
Do you feel nauseated or queasy with your headache?
What things trigger your
headaches? (foods, smells,
things in your environment,
etc.)
Many patients have pain that seems different than their typical headaches. Often these pains are felt in the sinuses, neck or
shoulders. If you have ANY type of pain in or around the head at all please circle the number of days per month you experience
this pain. Circle the ONE NUMBER that fits you best.
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Check the appropriate answer to the following yes/no questions:
Have you seen doctors other than your family doctor about your headaches?
Have you ever had a CT (CAT) scan?
Have you ever had an MRI scan?
Have you ever had a spinal tap (lumbar puncture)?
Have you ever had blood tests?
YES
NO
GENERAL MEDICAL HISTORY FORM
QUESTIONS
What NON-Prescription
meds are being used for any
reason?
ANSWER
What prescription meds are
you taking currently?
What medications have been
tried before?
What alternative therapies
have been tried?
Acupuncture
List any medical illnesses
you have ever had. Please
put the year next to the
name of the illness. If you
still have the illness, just put
the year it first started.
List any surgeries you have
ever had and the year when
they took place.
List your immediate family
members medical illnesses.
If there are other illnesses
you wish to list that have
occurred in other family
members (grandparents,
aunts, uncles, cousins, etc)
you may do so as well.
List the jobs you have done
or have been doing in the
last 10 years.
If you are out of work please
state why and for how long?
List allergies to medications
you know of and what
reaction you have to that
medication:
Are you married or have you
ever been married? If yes
for how long? If no, are you
in another relationship and
for how long?
FATHER:
MOTHER:
SIBLINGS:
CHILDREN:
OTHER:
Biofeedback
Craniosacral
therapy
Herbal
Therapy
Hypnosis
Massage
Therapy
Other:
Circle things that you drink
nearly every day:
Water
Tea
Regular Soda
Diet
Drinks
Decaffeinated
Drinks
Regular
Coffee
Milk
Circle things that you drink a few
times per week:
Water
Tea
Regular Soda
Diet
Drinks
Decaffeinated
Drinks
Regular
Coffee
Milk
Did you ever smoke?
YES
NO
If yes, for how long?
Do you still smoke?
YES
NO
Please circle the answers that seem most appropriate for your CURRENT use of alcohol (beer, wine, liquor):
I have
0
1
2
3
4
5
More than 5
drinks every
Day
Week
Month
Year
Month
Year
Please circle the answers that seem most appropriate for your PAST use of alcohol (beer, wine, liquor):
I once
had
0
1
Have you ever had a
blood transfusion?
2
3
YES
4
5
NO
More than 5
drinks every
Day
Week
If yes, when did it occur and have you been hepatitis/HIV tested since that time?
YES
Any history of IV drug use (cocaine, heroine, etc.)?
NO
About 50% of our patient population has experienced single or multiple events of physical, sexual, or emotional abuse by strangers,
acquaintances, or family members. Although these experiences are not causative for headache or pain, they may be contributory. We
ask that you think about this question and if you feel comfortable, please write in the space below if you have had such an experience.
If you do not wish to write about the experience, you may choose to share it with the physician during the office visit. Thank you for
your patience and candor with this question. IF YOU HAVE NOT HAD SUCH AN EXPERIENCE PLEASE ANSWER NO.
YES
NO
Please circle ANY of the following problems in the past or present that may apply. If the problem occurs only during
headache please put an “H” next to it. Please write next to the item about when the problem first started:
Weakness
Numbness
Balance difficulty
Vertigo (room spins)
Swallowing problem
Speech problem
Visual change
Hearing change
Shortness of breath
Chest pain
Loss of urine control
Loss of bowel control
Snoring
Wake up from snoring
Twitching/kicking in sleep
Sore legs at night
Restlessness during the day
Sleepy during the day
Clench jaws during the day
Insomnia (long time to fall
asleep)
Grind teeth in sleep
Feelings of guilt
Low energy
No enjoyment from previously
enjoyable activities
Decreased sex drive
Wake up repeatedly at
night
Low self-esteem
Nausea
Vomiting
Constipation
Diarrhea
Joint pain
Muscle pain
Back pain
Neck pain
Decreased memory
Word finding difficulty
Decreased concentration
Night sweats/hot flashes
Pneumonia
Bronchitis
Hepatitis
Mononucleosis
Kidney or bladder infection
Digestive problems
Toothaches or jaw pain
Braces
Decreased sexual function
Physician Notes:
HIT-6 =_______
Height
Weight
BMI
BP
Pulse
Pain
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