Date: ____________________

Patient's name _________________________________       Age __________________

1. How long have you been suffering with headaches? ______________________________

2. How old were you when the headaches began? __________________________________

3. Do you know when a headache is coming on – Aura? _____________________________

4. How often do you get a headache? ____________________________________________

5. Please describe any aggravating or precipitating factors? _________________________

   __________________________________________________________________________

6. How long do the headaches last? _____________________________________________

7. Where is the pain located? ______________________________________________

8. Describe the pain ___________________________________________________________

9. On a scale of 1 – 5 how strong is the pain? ______________________________________

10. Are there any other symptoms? _________________________________________________

11. Are there any visual symptoms? ________________________________________________

12. Family history of headaches _________________________________________________

13. Impact of the headaches – how does it disrupt your life? ___________________________

14. Are the headaches disabling? ____    Can you work? _____    Do you have to lie down? _______

15. Previous diagnostic studies _________________________________________________

16. Previous medications tried __________________________________________________

17. Current treatment, if any ____________________________________________________