Pediatric Neurology
Weill Cornell Medical Center Barry Kosofsky, MD
New York Presbyterian Hospital Chief, Pediatric Neurology
505 E 70th Street 3rd Floor
Zuhal Ergonul, MD, PhD


Please complete this questionnaire. It will be an important part of your child’s medical record.

How did you learn about our practice?
Self-Referral (Internet/Family/Friend/Other)
Referring Physician:
Please bring to your appointment any and all reports of previous neurological testing or consultation, or
reports of significant past medical problems.
If your child ever had a brain x-ray, CT, or MRI, please borrow the films or obtain a copy of the films and
bring them with you to the visit.
The patient should complete these questions. If a parent/guardian is completing this form, please
make sure the responses are the patient’s.

Headache History

Do you have more than one headache type?
No Yes (If yes, please answer the following questions for your first headache type, then describe your second headache on last
1. Are you ever headache free:
2. Onset of First Headache: Headaches started when I was years old.

3. Precipitating Events
What provoked your first headache?

4. Frequency:
How many months has it been this frequent?

5. Durations:
How long do they last?
minutes hours days (with medication)
minutes hours days (without medication)

6. Severity:
How bad is the pain?
On a scale of 0 to 10, what is the severity of your headache? (0 = no pain; 5 = moderate pain; 10 = worst possible pain)
7. Location:

8. Sideness:
Does your headache occur on:
Sometimes on one side and sometimes on both sides 9. Character: What does the pain of the headache feel like?
Other: Does the pain usually feel like it is going:
10. Activity that worsens headache:
Does the headache change your activity level (i.e., stop playing or doing normal activities)? Does activity or playing make the headache worse? Does the headache hurt more when you walk up stairs? Does bending over or standing up make it worse? Does straining or coughing make it worse? Does resting or sleeping make your headache get better or go away?

11. What symptoms occur with the headache?
(Please review carefully and check)
Difficulty with - thinking / walking / using arms / talking Other

12. Do you have any changes in your vision before your headache begins?
(Questions for visual aura)
How soon after your headache starts do these symptoms begin? Minutes Do you have any of these symptoms without headache pain? 13. Premonitory Symptoms
Do you experience any of the following BEFORE the headache starts?
How long before the headache starts do you notice these signs?

14. Provoking Factors:
(things that bring on a headache)


Physical exertion:



Other triggers:

15. Relieving Factors:

16. Do you experience any of the following during your headache
17. Have you noticed any of these findings when you have a headache ?

Quality of Life Review:
3. Headache’s effect on ability to function: At what percentage are you able to function when you get a headache at school? At what percentage are you able to function when you get a headache playing?
Previous treatments: (please give name of provider, date, type of treatment and if it helped)
Name of Provider, Date, Type of Treatment What diagnosis? Previous Tests: (Please give dates and results) Result (Normal or Abnormal)

Previous Preventive Headache Medication: (please check any medication that you have taken every day for your headache)

Previous Abortive Headache Medication (please check any medication that you have taken for your headache)
Vitamins, other supplements or herbal medications for headaches: Have you ever been treated for your headaches in an emergency department? Have you ever been treated for your headaches in a hospital (stayed overnight)? Current Medications: (Bring your own medication list and dosing schedule if more than 5)
How often
If allergic, what reaction did you have?
Do you skip any meals?
Drinking: How much total fluids do you drink a day? (# of total ounces) or (# of glasses) Do you drink caffeine-containing beverages? How long do you usually exercise per day? minutes / hours (please circle) Sleeping: I get hours of sleep per night. Check all that apply: I have difficulty falling asleep I have trouble staying asleep I wake up during the night or early morning for no apparent reason Past Medical History:
What was the patient’s birth weight? lbs ounces Were there any problems during delivery? Have you ever been diagnosed with any medical or psychiatric problems? Have you had any of the following problems? Repeated episodes of stomach pain or vomiting (without headache) (For female patients) Menstrual History: At what age did your menstrual periods start? Are your headaches worse with your periods? Yes If you haven’t had a period OR they just started, do you have monthly headaches? Social History
Who lives in the same house with the patient? What grade are you currently in at school? School performance (i.e grades) Have your headaches caused your academic performance to change? Any unusual stresses at home or at school? If so, what is your occupation? Have your headaches caused your work performance to change? Family History
Please check the box if your family members have had ANY of the following and list the person’s relationship to the patient next to the problem:
Review of Systems: (please check)
If you have more than one headache type, please use this space for your second headache:
Describe your second headache type:
PedMIDAS** (Pediatric Migraine Disability Assessment) The following questions try to assess how much the headaches are affecting day-to-day activity. Your answers should be
based on the last three months. There are no “right” or “wrong” answers so please put down your best guess.
1. How many full school days were missed in the last 3 months due to headaches?
2. How many partial days of school were missed in the last 3 months due to headaches (do not
include full days counted in the first question)?
3. How many days in the last 3 months did you function at less than half your ability in school
because of a headache (do not include days counted in the first two questions)?

4. How many days were you not able to do things at home (i.e., chores, homework, etc.) due to a

5. How many days did you not participate in other activities due to headaches (i.e., play, go out,
sports, etc.)?

6. How many days did you participate in these activities, but functioned at less than half your
ability (do not include days counted in the 5th question)?

Total PedMIDAS Score

Parent/Guardian/Patient Signature Date
Physician Signature Date
Please return this questionnaire to [email protected] prior to the doctor’s visit.
*This questionnaire is modified from Jefferson Headache Center and Cincinnati Children’s Hospital Headache Center Questionnaires and authored by Zuhal Ergonul, MD. PhD. **PedMIDAS: Development of a questionnaire to assess disability of migraines in children. Hershey AD, Powers SW, Vockell AL, LeCates S, Kabbouche MA, Maynard MK. Neurology. 2001 Dec 11;57(11):2034-9.
Race and Ethnicity Information

We want to make sure that all our patients get the best care possible. We would like you to tell us your
child’s racial and ethnic background as well as your preferred language so that we can review the
treatment that all patients receive and make sure that everyone gets the highest quality of care. You may
decline to answer if you wish.
The only people who see this information are registration staff, administrators for the practice, your care
providers, and the people involved in quality improvement and oversight, and the confidentiality of what
you say is protected by law.
Please mark the appropriate response:
Primary Language

Native Hawaiian or Other Pacific Island Ethnicity

Not Hispanic or Latino or Spanish Origin
Pharmacy Information

So that you and your physician may take advantage of e-prescribing, we need you to provide
information on the pharmacy that you choose to use to fill you or your child’s prescriptions. Electronic
prescription requests are more efficient, accurate and cost effective. Feel free to speak with your
physician if you have additional questions.

Patient Name:
NYH #:
Pharmacy Name:
Phone Number:
Fax Number:
SECONDARY (if applicable)
Pharmacy Name:
Phone Number:
Fax Number:

Source: http://weillcornell.org/pdf/pediatrics/neurology/HeadacheQuestionnaire2013.pdf

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