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