Headache Questionnaire (p1)

Check the appropriate box that best describes your headaches Migraine Tension Type Cluster In the past 3 months, my headaches were (check only one): Mild to moderate — — — Moderate to severe — — — Extremely severe — — — My headaches occur on (check only one): One side of my head — — — Both sides — — — In or around one eye — — — My headaches are best described as (check only one): Pounding, throbbing, or pulsating — — — Like a steady ache or pressure — — — Stabbing, piercing, in or around one eye — — — When I have a headache, I usually (check only one): Lie down in a quiet, dark room — — — Carry on with normal activities — — — Cannot keep still because of pain — — — Check only those that apply: I sometimes see wavy lines, spots, sparkling or colored lights before my headaches — — — During my headaches I sometimes feel sick to my stomach or vomit — — — During my headaches one eye becomes red and watery — — — Females only: My headaches often occur around the time of my period — Have you ever received a diagnosis of migraine headaches? ❑ Yes ❑ No This questionnaire is designed to assist physicians in the differential diagnosis of three common primary causes of headache. This questionnaire is not intended to differentiate primary headaches from secondary headaches. Secondary causes of headache should be ruled out before data collected using this form can be interpreted. Derived from the International Headache Society’s headache diagnostic criteria (Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgia and facial pain. Cephalalgia. 1988;8[suppl 7]:1–96). — — ©2002 Merck & Co., Inc. All rights reserved. 20204698(3)-12/02-MAX Printed in USA

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Headache Profiler ® ©2002 Merck & Co., Inc. All rights reserved. 20204698(3)-12/02-MAX Printed in USA Patient Name: _____________________________________________________ Phone:___________________________________ Address, City, State, ZIP:_______________________________________________________________________________________ Date of Birth:_____________________________________________________ Age:_______________________ Sex: K M K F (Please print clearly.)

Transcript of Headache Questionnaire (p1)

Headache Profiler ®

(Please print clearly.)

Patient Name: _____________________________________________________ Phone:___________________________________

Address, City, State, ZIP:_______________________________________________________________________________________

Date of Birth:_____________________________________________________ Age:_______________________ Sex: q M q F

Check the appropriate box that best describes your headaches Migraine Tension Type Cluster

In the past 3 months, my headaches were (check only one):Mild to moderate — — —Moderate to severe — — —Extremely severe — — —

My headaches occur on (check only one):One side of my head — — —Both sides — — —In or around one eye — — —

My headaches are best described as (check only one):Pounding, throbbing, or pulsating — — —Like a steady ache or pressure — — —Stabbing, piercing, in or around one eye — — —

When I have a headache, I usually (check only one):Lie down in a quiet, dark room — — —Carry on with normal activities — — —Cannot keep still because of pain — — —

Check only those that apply:I sometimes see wavy lines, spots, sparkling or colored lights before my headaches — — —During my headaches I sometimes feel sick to my stomach or vomit — — —During my headaches one eye becomes red and watery — — —

Females only:My headaches often occur around the time of my period —

Have you ever received a diagnosis of migraine headaches? q Yes q No

This questionnaire is designed to assist physicians in the differential diagnosis of three common primary causes of headache. This questionnaire is not intended todifferentiate primary headaches from secondary headaches. Secondary causes of headache should be ruled out before data collected using this form can be interpreted.

Derived from the International Headache Society’s headache diagnostic criteria (Headache Classification Committee of the International Headache Society. Classificationand diagnostic criteria for headache disorders, cranial neuralgia and facial pain. Cephalalgia. 1988;8[suppl 7]:1–96).

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