Pre-appointment questionnaire for headache/migraine patients Step 1 of 714%The Purpose Of This Questionnaire We would like you to fill in this questionnaire before you arrive for your first appointment to:help you to reflect on how your headaches or migraines have developed, possibly quite a while ago.enable you to give us the information we need to treat your headache effectively.Name*D.O.B* DD slash MM slash YYYY Email* 1. HEAD REGIONAre your headaches more prominent on one side of your head?* Right Left BothDo your headaches alternate from one site to the other?* Yes NoPlease mark one or more regions of your pain on the diagram* 1 2 3 4 5 6 7 8 92. HISTORYWhen did you start getting headaches?*How often do you get headaches?*How long do your headaches last for?*What severity range are your headaches? Mark on scale below.Mark for your least pain.Mark for your worst pain.3. ASSOCIATED SYMPTOMSTick any of the following symptoms that can be a feature of your headache.* Dizziness Visual disturbances Nausea Joint Pains Drop attacks Vomiting None4. PRESENTATION OF HEADACHESIs there anything you do that ALWAYS triggers a headache?*What medications do you use and how often?*Are there any other relieving factors?*What do you do when you get your worst headache?*5. HAVE YOU HAD A MAJOR NECK/HEAD TRAUMA?For example Head Injury Whiplash Injury OtherOther*If so, when?HIT-6TM Headache Impact TestHIT is a tool to measure the impact headaches have on your ability to function on the job, at school, at home and in social situations. Your score shows you the effect that headaches have on normal daily life and your ability to function.To complete, please choose one answer for each question.When you have headaches, how often is the pain severe?* Never Rarely Sometimes Very Often AlwaysHow often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities?* Never Rarely Sometimes Very Often AlwaysWhen you have a headache, how often do you wish you could lie down?* Never Rarely Sometimes Very Often AlwaysIn the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches?* Never Rarely Sometimes Very Often AlwaysIn the past 4 weeks, how often have you felt fed up or irritated because of your headaches?* Never Rarely Sometimes Very Often AlwaysIn the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities?* Never Rarely Sometimes Very Often AlwaysHiddenTotal HITCAPTCHA
