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PATIENT INSTRUCTIONS FOR COMPLETING THE PATIENT HEALTH/HISTORY QUESTIONNAIRE: - page 4 / 14

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HEADACHE HISTORY

In childhood

Between 20-30

Stress/tension

In teens

Between 30-50

Anxiety

Over 50 years old

Fatigue

The Headaches Began:

Precipitating Factors:

Cause of Headaches at Onset:

  • Certain foods

  • Alcohol

  • Perfumes

  • Exertion/activity

  • No known cause

  • Stress

  • Accident or injury

  • Exertion/activity

  • Coughing/sneezing

  • Certain medications

  • Weather changes

  • Positional change

  • Menstruation

Daily

For months Weekly

For years

For months Monthly

For years

For months Few times a year

For years

Frequency of Headaches:

Mild

Severe

Moderate

Incapacitating

Severity of Headaches:

Hormonal (women):

  • The headaches are associated with the menstrual cycle

  • The headaches are associated with birth control therapy

  • The headaches are associated with any hormone therapy

  • The headaches worsened with pregnancy

  • The headaches improved with pregnancy

  • The headaches started in menopause

Warnings (Prodrome) Before Headache Starts:

Activity Level During a Headache:

  • Can continue normal activities

  • Normal activities are impaired

  • Must stop activity and rest awhile

  • Must go to bed

  • Totally incapacitated

Headache Reaches Maximum Intensity in:

Seconds

Hours

Minutes

Days

  • Craving for sweets

  • Upset sto

  • Nausea

  • Diarrhea

  • Dizziness

mach

  • Personality change

  • Depression

  • Hyperactivity

  • Muscle aching

  • Visual disturbance

Insomnia

Sleep disorder

Sleep takes away

Snoring

Sleep:

the headache

Duration of Headache:

  • Lasts seconds without treatment

  • Lasts 15-30 minutes without treatment

  • Lasts hours without treatment

  • Lasts days without treatment

  • Lasts 1-2 hours with immediate treatment

  • Lasts 2-4 hours with immediate treatment

  • Lasts 4-24 hours with immediate treatment

  • Lasts days with treatment BAYLOR UNIVERSITY MEDICAL CENTER DALLAS, TEXAS

52334 (Rev. 03/10)

PATIENT HEALTH/HISTORY QUESTIONNAIRE Page 2 of 11

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