First Name: Last Name:
Date of Birth : Phone Number :
Email :
1. How many types of headache do you have ?
2. How long have your headaches been the way they are now?
3. How often do you get a headache?
4. Do you have days without a headache?
5.How long does your headache typically last?
6.What do you typically do when you get a headache?
7.Are you able to continue regular activities or not?
8.Do you get nauseous or have sensitivity to sound or light when you get a headache?
9.Are you having a headache right now?
10.If so, is this as severe as it usually gets ?
11.Where does your headache usually occurs ?
12.Is the pain in the same spot or does it changes sides of the head?
13.Is your headache dull, sharp or throbbing?
14.Have you developed any other health problems since your headaches began or changed?
15.Have you noticed a pattern to when your headaches occur or get worse?
16.What do you take when you get a headache?
17.Do you take herbal medications or nutritional supplements?
18.Have you recently changed any of your medications?
19.Do your headache wake you from sleep?
20.Do you have a runny nose, drooping eyelid or tearing of the eye when you have a headache?