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PATIENT INSTRUCTIONS FOR COMPLETING THE PATIENT HEALTH/HISTORY QUESTIONNAIRE: - page 1 / 14

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PATIENT INSTRUCTIONS FOR COMPLETING THE PATIENT HEALTH/HISTORY QUESTIONNAIRE:

  • A)

    This detailed questionnaire of your health history is extremely important. Your past health experiences play a major role in developing a successful treatment program for your headaches. Please take the time to fill out and complete this form to the best of your ability.

  • B)

    If any item or statement on this form applies to you, please check the square corresponding to that item or statement.

C) Those items or statements which do not apply to you are to be left blank.

Cardiovascular

Past

Present

Hypertension

D) Example #1 - Under: Past Medical History

Check the corresponding square only if you have had or have Hypertension; OTHERWISE LEAVE BLANK.

Example #2 - Under: Social History Daily caffeine consumption

  • Never

  • Occas

ional

  • Moderate

  • Excessive

Mild

Severe

Moderate

Incapacitating

Check the corresponding square which applies to you.

Example#3 - Under: Severity of Headache

Only Check the square which applies to you.

  • E)

    On designated pages of the questionnaire you are asked to write additional information. There is space provided for any further descriptive information you may feel is important or may be helpful.

  • F)

    Please do not write the additional information on those pages of the questionnaire where you are asked to only check the squares corresponding to a particular item or statement.

G) All the information obtained on the Patient Health/History Questionnaire will be evaluated at the time of consultation.

BAYLOR UNIVERSITY MEDICAL CENTER DALLAS, TEXAS

52334 (Rev. 03/10)

PATIENT HEALTH/HISTORY QUESTIONNAIRE Page 1 of 1

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