UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL

HEADACHE HISTORY FORM

NUTRITION FOR CHRONIC DAILY HEADACHE

Name:
DATE OF BIRTH:
MEDICAL RECORD NUMBER:
SEX: Female Male
RACE: African American American Indian Asian American Caucasian Hispanic Other
Name of your neurologist and city where his/her office is located:
Name of your family doctor and city where his/her office is located:
questions
/ YES / NO / Explanation
(If yes put details here)

Did you ever have headaches that put you in bed or took you out of school or activities as a child?

Did you ever see a doctor for childhood headaches?

Ever been carsick?

Ever had head, neck, or jaw injury?
Ever lost consciousness for any reason?
Ever had a fall on your back or tailbone?
Ever had a motor vehicle accident?
Have you seen doctors other than your family doctor about your headaches?
If you are female, have you ever had a headache near your menstrual cycle? /

If yes, when during your cycle?

If you are female, do you still have menstrual periods? /
If female, how old were you with your 1st menstrual period? / ----- / ----- / Age=
If female, have you ever been pregnant? / How many times?
How many children do you have living?
I first started having headaches at age: / Write age in years here
My most recent headaches started at age: / Write age in years here

Please circle the answer that seems best to each of the following questions:

In an average week I have about this many total headaches: Circle one number:
0 / 1 / 2 / 3 / 4 / 5 / 6 / 7
In an average week I have about this many SEVERE headaches: Circle one number:
0 / 1 / 2 / 3 / 4 / 5 / 6 / 7
If I counted all my headaches I had in a month, the number of days WITHOUT ANY headache at all in a month would be: (CIRCLE ONE NUMBER THAT FITS YOU BEST )
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
My headaches are: / Aching / Throbbing/pounding / Pressure/squeezing / Stabbing / Shooting
My head hurts: / On one side / On both sides / In the front / In the back / All over
My headache, when severe, is worse with:
Smells / Foods / Bright Light / Loud Noise
Moving my head / Lying down / Standing Up / Walking the stairs
My headache usually lasts:
Less than 1 minute / Less than one hour / 1-3 hours / 4-12 hours
13-24 hours / 25-48 hours / More than 48 hours / It never goes away
When I have a headache, I:
Keep doing what I was doing / Take a pill and keep doing what I was doing / Have to lie down
Check the appropriate answer to the following
yes/no questions: / YES / NO / EXPLANATION
Do you get a warning that a headache is coming?
Do you throw up with your headaches?
Does your neck hurt when you have a headache?
Do your eyes and/or nose run when you have a headache?
Do you feel nauseated or queasy with your headache?
What things trigger your headaches? (foods, smells, things in your environment, etc.)
Check the appropriate answer to the following yes/no questions: / YES / NO
Have you seen doctors other than your family doctor about your headaches?
Have you ever had a CT (CAT) scan?
Have you ever had an MRI scan?
Have you ever had a spinal tap (lumbar puncture)?
Have you ever had blood tests?
Many patients have pain that seems different than their typical headaches. Often these pains are felt in the sinuses, neck or shoulders. If you have ANY type of pain in or around the head at all please circle the number of days per month you experience this pain. Circle the ONE NUMBER that fits you best.
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

GENERAL MEDICAL HISTORY FORM

Questions

/

Answer

What NON-Prescription meds are being used for any reason?
What prescription meds are you taking currently?
What medications have been tried before?
What alternative therapies have been tried? / Acupuncture / Biofeedback / Craniosacral therapy / Herbal Therapy / Hypnosis / Massage Therapy / Other:
List any medical illnesses you have ever had. Please put the year next to the name of the illness. If you still have the illness, just put the year it first started.
List any surgeries you have ever had and the year when they took place.
List your immediate family members medical illnesses. If there are other illnesses you wish to list that have occurred in other family members (grandparents, aunts, uncles, cousins, etc) you may do so as well. / FATHER:
MOTHER:
SIBLINGS:
CHILDREN:
OTHER:
List the jobs you have done or have been doing in the last 10 years.
If you are out of work please state why and for how long?
List allergies to medications you know of and what reaction you have to that medication:
Are you married or have you ever been married? If yes for how long? If no, are you in another relationship and for how long?

Circle things that you drink nearly every day:

/ Water / Tea / Regular Soda / Diet Drinks / Decaffeinated Drinks / Regular Coffee / Milk

Circle things that you drink a few times per week:

/ Water / Tea / Regular Soda / Diet Drinks / Decaffeinated Drinks / Regular Coffee / Milk
Did you ever smoke? / YES / NO / If yes, for how long? / Do you still smoke? / YES / NO
Please circle the answers that seem most appropriate for your CURRENT use of alcohol (beer, wine, liquor):
I have / 0 / 1 / 2 / 3 / 4 / 5 / More than 5 / drinks every / Day / Week / Month / Year
Please circle the answers that seem most appropriate for your PAST use of alcohol (beer, wine, liquor):
I once had / 0 / 1 / 2 / 3 / 4 / 5 / More than 5 / drinks every / Day / Week / Month / Year
Have you ever had a blood transfusion? / YES / NO / If yes, when did it occur and have you been hepatitis/HIV tested since that time?
Any history of IV drug use (cocaine, heroine, etc.)? / YES / NO
About 50% of our patient population has experienced single or multiple events of physical, sexual, or emotional abuse by strangers, acquaintances, or family members. Although these experiences are not causative for headache or pain, they may be contributory. We ask that you think about this question and if you feel comfortable, please write in the space below if you have had such an experience. If you do not wish to write about the experience, you may choose to share it with the physician during the office visit. Thank you for your patience and candor with this question. IF YOU HAVE NOT HAD SUCH AN EXPERIENCE PLEASE ANSWER NO.
YES NO

Please circle ANY of the following problems in the past or present that may apply. If the problem occurs only during headache please put an “H” next to it. Please write next to the item about when the problem first started:

Weakness / Numbness / Balance difficulty / Vertigo (room spins)
Swallowing problem / Speech problem / Visual change / Hearing change
Shortness of breath / Chest pain / Loss of urine control / Loss of bowel control
Snoring / Wake up from snoring / Twitching/kicking in sleep / Sore legs at night
Restlessness during the day / Insomnia (long time to fall asleep) / Sleepy during the day / Wake up repeatedly at night
Clench jaws during the day / Grind teeth in sleep / No enjoyment from previously enjoyable activities / Low self-esteem
Feelings of guilt / Low energy / Decreased sex drive / Decreased sexual function
Nausea / Vomiting / Constipation / Diarrhea
Joint pain / Muscle pain / Back pain / Neck pain
Decreased memory / Word finding difficulty / Decreased concentration / Night sweats/hot flashes
Pneumonia / Bronchitis / Hepatitis / Mononucleosis
Kidney or bladder infection / Digestive problems / Toothaches or jaw pain / Braces

Physician Notes:

HIT-6 =______Height Weight BMI BP Pulse Pain

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