Chronic Headache Assessment Proforma
Personal headache fact sheet
Your answer
Age *
Your answer
Sex *
Your answer
Email *
Your answer
Beginning of Headache
Months or Years since headache started.
Your answer
Age at Onset of Headache
Your age when the headache started.
Antecedent Cause
Any accident, injury or disease after which the headache might have started.
What according to you started headache ?
Your answer
Location of Headache
Specify the area of pain during headache.
Movement of Headache
Does the location of headache change ?
Type of Pain
Quality of the pain which troubles you.
Aura or Prodrome
Prior warning symptoms one hour or more telling that the headache is coming.
Types of Warnings
What warnings signal that a headache might be coming ?
Severity of Headaches
Rate the severity of headaches starting from mildest to most severe.
Most Severe
Effect on Activity Levels
Effect on your routine activities during the headache.
Worsening Factors
Factors which increase the severity, duration or frequency of headaches.
Associated symptoms
Any other effects on body or mind which come with headaches.
Disturbances in eye during headaches.
Relieving Factors
What relieves you of your headaches.
Trigger factors
Factors which start you headaches.
Relation to Menstrual Cycles
Any effect of menstrual cycles on headache.
Relation to Pregnancy
Effect of pregnancies on headaches.
Seasonal Relationship
Season in which headaches are more frequent.
Your answer
Family History
Any known relatives with chronic & severe headaches. ( List all)
Your answer
Headache Medications
Check the medicines for headaches you have been taking
Overuse or Abuse
Medicines taken more than three days a week.
Other Health Conditions
Any other illness diagnosed by a medical practitioner. (Name all)
Your answer
Surgical History
List any surgeries done on you.
Your answer
Social History
Socially relevant details
Smoking History
If you smoke then how much ?
Your answer
Alcohol Details
If you take alcohol specify how much and how frequently.
Your answer
Caffeine Intake
How much and how often you consume caffeine containing food / beverages.
Your answer
Family History
List diseases in family (if any) other than headaches.
Your answer
List of allergies (if any) to drugs, foods or anything else.
Your answer
Current Medicines
List medicines currently prescribed ( if any) for any other conditions.
Your answer
Other Symptoms
Check all other symptoms present.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms