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PATIENT INSTRUCTIONS FOR COMPLETING THE PATIENT HEALTH/HISTORY QUESTIONNAIRE: - page 7 / 14

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Ambien®

Doxepin®

Lorazepam

Prozac®

Amitriptyline

Duract®

Lorcet®

Relafen®

Anaprox®

Effexor®

Lorcet Plus®

Restoril®

Alprazolam

Elavil®

Lorcet HD®

Sansert®

Anaprox DS®

Endep®

Lortab®

Serzone

Apresoline

Ergotamine®

Lortab ASA®

Sinequan

Atenolol

Ergomar®

Lyrica®

Stadol®

Ativan®

Ergostat®

Meclomen®

Stadol NS®

Bellergal-S®

Esgic®

Medrol Dosepak®

Talwin®

Bextra

Fioricet®

Methadone

Thorazine®

Botox

Fiorinal®

Midrin®

Tofranil®

BuSpar®

Fiorinal w/Codeine®

Mobic

Tolectin®

Butalbital®

Fiorpap®

Morphine®

Topamax

Cafergot tablets®

Gabitril

Naprelan®

Tranxene®

Cafergot suppositories®

Haldol®

Napron X®

Trazodone®

Cataflam®

Hydrocodone

Naprosyn®

Triavil®

Celebrex®

Imipramine

Naproxen®

Tylenol No.3®

Celexa

Inderal®

EC-Naprosyn®

Tylenol No.4®

Clinoril®

Indomethacin®

Neurontin®

Tylox®

Codeine®

Indocin®

Nifedipine

Ultram®

Dalmane®

Indocin SR®

Norco®

Wellbutrin®

Darvon®

Indochron E-R®

Norpramin®

Valium®

Darvon Compound®

Indomethacin SR®

Orudis®

Valproic acid

Darvocet-N 100®

Isocom®

Oruvail®

Vioxx

Deltasone®

Isopap®

Pamelor®

Verapamil

Demerol®

Isometheptene/

Paxil®

Vicodin®

2010

2009

Past 5 years

2010

2009

Past 5 years

2010

2009

Past 5 years

2010

2009

Past 5 years

2010

2009

Past 5 years

2010

2009

Past 5 years

2010

2009

Past 5 years

2010

2009

Past 5 years

2010

2009

Past 5 years

Desipramine

Ketoprofen

Periactin®

Xanax®

D.H.E.-45®

Klonopin®

Phrenilin®

Xylocaine®

Diazepam

Lamictal

Prednisone®

Zoloft®

Dilaudid®

Lexapro

Procardia®

Zonegran®

Dilantin®

Lithium

Propranolol

Zanaflex®

  • Dolobid®

BAYLOR UNIVERSITY MEDICAL CENTER DALLAS, TEXAS

52334 (Rev. 03/10)

PATIENT HEALTH/HISTORY QUESTIONNAIRE Page 5 of 11

TEST / X-RAYS

  • Depakote®

  • Desyrel®

PLEASE FILL IN TH

E BOX FOR ANY LISTED MEDICATION EVER USED FO

R HEADACHES:

  • Vicodin ES®

  • Wigraine®

Test

  • Head CT

  • Head MRI

  • Cervical CT

  • Cervical MRI

  • EEG

  • Spinal Tap

  • Head MR Angiogram

  • Head CT Angiogram

  • Blood Tests

Year Performed

dichloralphenazone/ acetaminophen

  • Percocet®

  • Percodan®

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