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PATIENT INSTRUCTIONS FOR COMPLETING THE PATIENT HEALTH/HISTORY QUESTIONNAIRE: - page 6 / 14

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Past

Migraine Specific Medications: Imitrex tablet Imitrex nasal spray Imitrex injection Maxalt Zomig Amerge Axert Frova Relpax Treximet Cafergot tablets Cafergot suppository Migranal nasal spray DHE-45

Prescription Pain Medications: Butalbital Fioricet Fiorinal Esgic Fiorinal w/ codeine Phrenilin

Darvon

Darvocet

Oxycodone

Lorcet

Lortab

Vicodin

Norco

Vicoprofen

OxyContin OxyIR Percocet Percodan Roxicodone Tylox

Stadol nasal spray Ultram Tylenol No.3 or No. 4

Hydrocodone

Advil

Motrin

Nuprin

Naprosyn

Naprelan

MEDICATIONS Present Past Present Nonsteroidal Anti-Inflammatory Medications:

  • Ibuprofen

Naproxen

Aleve

  • Vioxx

  • Celebrex

  • Bextra

Combination Medications: Anacin Excedrin Midol

Aspirin Containing Medications: Aspirin Bufferin Ecotrin Alka Seltzer Sinus meds

Acetaminophen Containing Medications:

Tylenol

Other aspirin free pain meds

BAYLOR UNIVERSITY MEDICAL CENTER DALLAS, TEXAS

52334 (Rev. 03/10)

PATIENT HEALTH/HISTORY QUESTIONNAIRE Page 4 of 11

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