Headache Questionnaire

Department of Neurology Institute of Neurological Science Clinical Secretary: Direct Line: Direct Fax: Patient number: Dear Mrs Tracey 0141 201 2478 0141 201 2510 , Your next appointment is on . Please take the time to answer the questions below prior to the clinic appointment. Give the completed questionnaire to the Nurse when you arrive at the clinic. The information is confidential and will help the Doctor in assessing your case. Number per week Number per month How often are your headaches? Are the headaches the same as before? YES NO If no please specify_________________________________________________________________ _________________________________________________________________________________ Has there been any new symptoms? YES NO If yes,please specify__________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Page 2 Compared to when you last attended the clinic Are you - Better The same Worse Were you advised to take treatment by the Doctor at your last clinic appointment? If yes did you take the treatment? YES NO YES/NO If no why not? __________________________________________________________________________________ __________________________________________________________________________________ If yes, has the treatment helped YES Have you tried any other treatments yourself? YES NO NO If yes, please specify_________________________________________________________________ __________________________________________________________________________________ Has your own Doctor prescribed any new treatment for you? YES NO If yes, please specify_________________________________________________________________ __________________________________________________________________________________ Have you found anything else that helps your headaches? YES NO If yes, please specify_________________________________________________________________ __________________________________________________________________________________ Yours sincerely, Donald Grosset Consultant Neurologist Neurology Clinic Southern General Hospital Headache Proforma (Return) Patient number: How have you been since your last visit? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Are there any new symptoms? YES NO If yes, please specify __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Changes in Medication Tick if none Drug Name  Type of Reaction _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Examination: BP (Sitting): ______________________________ BP (Standing): __________________________ Pulse (Sitting): ____________________________ Pulse (Standing): ________________________ Corrected Visual Acuity: R __________________ L __________________ Fundi  Normal SVP (R) SVP(L) Abnormal ________ Temporal Arteries  Pulsatile and non tender Abnormal _____________________ Cranial nerves  Normal  Abnormal _____________________ Arms (Tone/Power) Sensation Normal Abnormal ______________________ Legs (Tone/Power) Sensation Normal Abnormal ______________________ Co-ordination  Normal Abnormal ______________________ Reflexes  Normal Abnormal ______________________ Other comments: _________________________________________________________________________ Page 2 Summary of investigations to-date Tests/Inv. Done before (tick if YES) Comment on Result Done in clinic Comment on Result Further investigations requested Outcome of clinic visit Diagnosis             Migraine without aura Migraine with aura Tension-type headache Chronic daily headache Cluster headache Post-traumatic headache Benign intracranial hypertension Drug induced Cervical spondylosis No diagnosis made Structural lesion (please specify): _____________ Other: ____________________________________ 2.      Treatment Recommended Prophylaxis Propranolol  80 mg LA  Other: ____________ Sanomigran  0.5 mg  1.5 mg  1.5 mg  Other: ________ Cyproheptadine  4mg increased weekly to tid Other: ______________________ Amitriptyline 75 mg 150 mg Other: ______________________ Acute Ibuprofen 200 mg 400 mg Other: ______________________ Domperidone  10 mg  Other: ____________________________________ Sumatriptan Tablets 50 mg Tablets 100 mg Nasal Spray 20 mg Injection 12 mg Naratriptan  2.5 mg Zolmitriptan  2.5 mg Rizatriptan  10 mg Other 1 Other 2 3. Side effect discussed         Yes 2.     1. Discharged back to GP Admitted Continuing to attend as out patient Awaiting further investigation as out patient  Other: _______________________  Pregnancy/Contraception issues

Headache Questionnaire

Related documents

Products

Support

Headache Questionnaire

Related documents

Add this document to collection(s)

Add this document to saved

Suggest us how to improve StudyLib