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PATIENT INSTRUCTIONS FOR COMPLETING THE PATIENT HEALTH/HISTORY QUESTIONNAIRE: - page 5 / 14

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HEADACHE HISTORY (Continued)

Family History of Headache:

  • Mother's side (maternal)

  • Father's side (paternal)

  • Brothers

  • Sisters

  • Children

Location of Headache:

  • On the left side of head

  • On the right side of head

  • Over left eye

  • Over right eye

  • Over both eyes

  • Over whole head

Symptoms of the Headache:

  • Pain lasts between 4-72 hours

  • Pain is throbbing or pounding

  • Pain is worse on just one side of the head

  • Pain inhibits daily activity

  • Nausea may occur with the headache

  • Vomiting may occur with the headache

  • Intolerance to light (photophobia)

  • Intolerance to noise or sounds (phonophobia)

  • Visual changes occur before headache

    • Blurred vision

    • Loss of half of vision

    • Loss of vision in one eye

    • White or colored geometric figures (photopsias)

      • Spots or sparks

      • Flashes of light

      • Streaks of light/wavy lines

    • Shimmering geometric designs (fortification scotoma)

      • Honeycomb patterns

      • Crescent shaped

      • Horseshoe shaped

  • Numbness/tingling in arms or legs

  • Numbness/tingling in trunk

  • Numbness/tingling in face

  • Paralysis of arm or leg

  • Inability to properly use an arm or leg

  • Sudden acute, severe, excruciating, debilitating headache

    • The excruciating pain starts in minutes

    • The pain is immediately debilitating

    • The pain is in one eye

    • The eye becomes red

    • The eye starts to tear

    • The eyelid droops

    • There is sudden nasal congestion

    • There is sudden nasal discharge

    • The attacks occur daily

    • The attacks occur several times a day

    • The attacks occur every other day

  • The headache is of mild to moderate intensity

  • The headache does not prohibit daily activity

  • The headache may last up to seven days

  • The headache is without nausea

  • The headache is without vomiting

  • The headache is without intolerance to light

  • The headache is without intolerance to noise/sound

  • The headache is like a vise around the head

  • The headache is in a hat band distribution

  • The headache is over the whole head

  • The headache is not aggravated by physical activity

Effects of the Headache:

  • Daily activities have changed

  • The headaches affect work performance

  • Social activities are limited

  • The headaches have caused marital problems

  • The headaches have led to depression

  • The headaches have led to seeing a

psychiatrist

  • The headaches have led to seeing a counselor

BAYLOR UNIVERSITY MEDICAL CENTER DALLAS, TEXAS

52334 (Rev. 03/10)

PATIENT HEALTH/HISTORY QUESTIONNAIRE Page 3 of 11

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