Headache Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Please enable JavaScript in your browser to complete this form.Name *FirstLastMarital statusMarriedSingleDivorcedWidowHow many Headaches you experience each week__________ on average. How many Headaches you experience each month____________on average. How long does your typical headache last: Check one? No more than two hours.Three to four hours.5-12 hours.12-24 hours.Several days.Week or longer. Do you have generalized discomfort or occasional headache to pinpoint?Never / don't knowOccasional moderate discomfortFrequent moderate discomfortOccasional severe painFrequent severe painCan you predict your headaches? I can never predict headachesIt seems as though I have a headache every dayI sometimes get a headache, never more than 2 or 3 times a month.I suffer from more than 2-3 times a month headaches.Do these headaches interfere with your ability to perform your daily tasks?Headaches never interfere with my lifeThese headaches bother me, but I can grin and bear it, and continue through the dayMy headaches are so bad that I have to stop what I'm doing to go and lie down in a quiet room.Where does your head hurt?I cannot pinpoint exactly where it is painful.My whole head feels as though it is gripped in a vice.Only one side of my head is hurting.If yes explain: Right or left. How would you best describe your headache? Dull, constant pain.Severe throbbing pain that feels as though your heart is pounding inside your head.Throbbing pain like hammer are striking.Do any of the following symptoms coincide with your headache?Neck pain.Normally, I only have the headache on its own.Nausea or vomiting.Sensitivity to light or noiseDo you ever experience any warning signs before you get a headache? No, my headache builds up gradually.If I get nightmares, they are usually followed by headaches the next day.I sometimes see flashing lights, dark spots or wavy lines before my eyes and then I know the pain will arrive soon.Have you ever thought your headache was brought on by one of the following?Change of seasons.Any form of stressful event.Chocolates, coffee or red wine (not a hangover).None of the above.Do you have sensitivity to light? YesNoNeverHave you ever noticed a relationship between your menstrual cycle and your headache?Sometimes my headaches coincide with my menstrual period, but I don't consider it a pattern, since I often have headaches outside my menstrual periodNoMy headaches always occur 3 days before, or during my menstrual period.Does not apply to me.Have you ever noticed a relationship between sexual activity and your headache?My headache feel better after sexual activityNo my headaches get worst after.I don’t see any relationship to my headaches.My headache is related to my emotional status. I only get headaches when I am depressed.I get depressed more due to the fact that I constantly have headaches.My PMS mood swings trigger the headache Have you ever been diagnosed as suffering from migraine?NoYesI m unsure. Your pregnancy status?This is my first pregnancy.It happened in previous pregnancies.No my previous pregnancies been fine(no headaches).Have you ever had any hormone issues before getting pregnant?I never took any hormonal treatment or fertility pillsYes, I took some treatmentI took birth control pills.None of the above. Did you ever been diagnosed with thyroid related issues?Yes I have low (hypothyroidism)Yes I have high (hyperthyroidism).No my TSH numbers were OKI took the medicines for thyroid problems in the past but it was OK.WebsiteSubmit