MIGRAINE/HEADACHE QUESTIONNAIRE PLEASE PRINT Name: ________________________________ Date: __________________________ 1) AGE: How old were you when you had your first migraine headache?____________ a) For Females: Was it with onset of menstruation (period)?____________________ b) Was there any specific event that occurred that you could relate to the onset of migraines, or did it come on gradually? ___________________________________________________________________ ___________________________________________________________________ 2) PAST HISTORY: a) Does anyone else in your family (i.e. mother, father, grandparents, or other family members) have migraine headaches? ___________________________________________________________________ b) Have you ever been formally evaluated for your headaches? __________________ i) If yes, By whom and when? __________________________________________ ii) Was the doctor a neurologist?________. If not, indicate what type of specialist diagnosed your migraine.___________________________________________ iii) Did you ever have a CT scan or MRI scan of your head? __________________ ---If yes, what were the results? _________________________________________________________________ _________________________________________________________________ c) Over the past 5 years, have your headaches worsened? Stayed the same? Improved? ___________________________________________________________________ d) Do you get chronic daily headaches or tension headaches in addition to migraines? __________. If yes, please describe. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 3) FREQUENCY: How many times per month do you get a migraine headache? _____________________________________________________________________ 4) DURATION: How long does your headache last (in days)? ___________________ 5) SEVERITY: On a scale of 1-10 (with 10 being the worst), how would you rate your headache pain? ______________________________________________________ Headache questionnaire 14601 S. Bascom Ave. Ste. 240 Los Gatos,Ca 95032 Telephone. 408-356-0503 Page 1 of 4
Maia U. Chakerian, MD Board Certified Specialist in Pain Medicine
6) DISTRIBUTION: Please describe specifically where on your body you typically get the headache pain? For example: Is the pain on one side or both sides of your head? Where does it usually start? Does it shift from side-to-side? Is it found behind your eyes? Does the pain distribution also include your neck? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ 7) Please describe any other specific or unusual details that might characterize your headache. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 8) AURA: Definition: An aura is a “feeling of disconnection” prior to an actual migraine headache. Do you typically experience an aura before your migraine headaches?____ If yes, please describe: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 9) ASSOCIATED SYMPTOMS: Please indicate whether you experience the following Symptoms when you get migraine headache pain (yes or no):
a) Nausea? ___________ b) Vomiting? _________ c) Photophobia (sensitivity to light)? ______________ d) Phonophobia (sensitivity to sound)? _____________ e) Please describe any other associated symptom(s) that you may experience during a
migraine headache: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Headache questionnaire 14601 S. Bascom Ave. Ste. 240 Los Gatos,Ca 95032 Telephone. 408-356-0503 Page 2 of 4 Maia U. Chakerian, MD Board Certified Specialist in Pain Medicine 10) MEDICATIONS AND TREATMENTS: a) Please list all current medications that you take for migraine headaches. Also list any side effects you may be experiencing from use of this medication(s). ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ b) Please list all medications that you have taken in the past that for any reason you are now unable to take, or which were not effective. Please list any side effects you may have experienced. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ c) Do you currently take the drug IMITREX or similar type drug?______. If so, does it relieve your headache? ________. How long does this drug provide relief (in hours)?________. How long have you been taking Imitrex (or any similar drug)?________. Do you find Imitrex (or similar drug) to be: a) more effective; b) less effective; or c) just as effective now as when you first began taking the medicine? _________. What side effect do you experience with Imitrex or similar type drug? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ d) Other than medication, are there any other treatments (i.e. acupuncture or homeopathic remedies) that you use to help relieve your migraine headache pain? (Yes or No) __________. If yes, please describe: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ f) What do you do if medications do not relieve your headache? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Headache questionnaire 14601 S. Bascom Ave. Ste. 240 Los Gatos,Ca 95032 Telephone. 408-356-0503 Page 3 of 4
Maia U. Chakerian, MD Board Certified Specialist in Pain Medicine ________________________________________________________________________ 11) JOB/ LIFESTYLE: a) If currently employed, approximately how much time (hour/month on average) do you miss from work? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ b) How do migraine headaches affect planning for your daily activities? ________________________________________________________________________ ________________________________________________________________________ c) How do migraine headaches affect your overall life? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 12) OTHER MEDICAL HISTORY:
a) Do you have any other medical problems? (Please list) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 13) PLEASE LIST ALL MEDICATIONS TAKEN: Name of Medication Frequency Date started Prescriber ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 14) ALLERGIES: ________________________________________________________________________ 15) PAST SURGERIES AND DATES: ________________________________________________________________________ ________________________________________________________________________ Headache questionnaire 14601 S. Bascom Ave. Ste. 240 Los Gatos,Ca 95032 Telephone. 408-356-0503 Page 4 of 4
Sehr geehrte Frau Doktor,sehr geehrter Herr Doktor,wie gewünscht, senden wir Ihnen nachfolgend Musteranforderungen nach AMG § 47 Abs. 3 mit deren Hilfe Sie Ihr Arzneimittelbudget entlasten, sowie Kurzfassungen aktueller Newsund wissenschaftlicher Literatur, die Einfluss auf Ihren Praxisablauf nehmen können. Für alle Kurzmeldungen stehen weitergehende Informationen zur Verfügung, die wir Ihn
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