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					                                                                      Date:___________________

Headache Center

Patient History

Name                                           Date of Birth              Age            □M      □F
Address                                                                       Birthplace
                                                                               Zip Code
Phone (Home)                         (Work)                             (Cell)
Marital Status□S □M □W □Div □Sep                       Language              Race
Referred by: □primary care physician □other neurologist □family member □friend □other
Please provide your referring or regular doctor’s full name, address, phone number, and fax number.
All of this information is required in order to mail or fax a letter to your doctor.
Referring Physician or Primary Care Doctor:
        Address:

      Phone:                           Fax:
Pharmacy Phone Number:
Why will you be coming to the clinic/Why are you here?


Headache History #1
     Do You Have More Than One Headache Type?            □Yes □No    (if Yes, please complete pages 6-9)
     Briefly describe headaches here:




1.     Onset Of First Headache:
       Headaches started ____ years ago.   I was: _____ years old.

2.     Precipitating Event (what provoked you first headache):
              □None known                         □Injury
              □Menarche (first period)            □Pregnancy
              □Other:
3.     Have your headache become more frequent or severe since the onset? Briefly describe here:




                                                                                                       1
4.      Location of Pain:
        □Temples (temporal)                              □Eye
        □Back of head (occipital)                        □Ear
        □Side of head (parietal)                         □Neck
        □Front of head (frontal)                         □Jaw
        □Around head (holocranial)                       □Other:________________________
4.      Sidedness:                                      Changes Sides:
        □Right-sided                                    □Between attacks
        □Left-sided                                     □During Attacks
        □Both Sides       □Varies                       □Both between and during
5.      Pain Characteristics:
        □Throbbing/Pulsing                              □Pressure
        □Achy                                           □Burning
        □Tight                                          □Searing
        □Dull                                           □Shooting
        □Stabbing                                       □Other_________________
6.
     (a) Severity: (How bad is the pain on a scale of 0 to 10: where 0 is no pain and 10 is the worst)
         Lowest and highest level of pain for this headache: Low_____ to High ______
         Usual severity of this headache type: ________
         Worse with menses?            □Yes □No
     (b) Headache disability during or after an attack:
         □Normal activity
         □Slight decrease in function
         □Moderate decrease in function
         □Severe decrease in function
         □Confined to bed
7.    Duration: (How long do they last?)
Lasts ___minutes ___hours ___days (with medication) | How often does it recur within 24 hrs?____%
Lasts ___minutes ___hours ___days (without medication) | How often does it recur within 24 hrs?___%
      □Headaches are continuous
8.      Frequency: (the number of attacks)
        ____#/day ____#/week ____#/month ____# per year ____# of lifetime attacks ____continuous
                Are they increasing in frequency?     □Yes □No
     (a) How many days in the last month did you experience headaches? (This includes all days of head or
         facial pain whether it be mild, moderate, or sever in intensity)
         _________days per month


                                                                                                            2
      (b) Based on your answer to question (a), how many of these days are your headaches moderate to severe
          in intensity? (For example, you may experience 20 days of headache per month, of which only 10 are
          moderate to severe in intensity)
          _________days per month

      (c) Are you ever HEADACHE FREE?     □Yes □No
         □Pregnancy □Vacation      □Weekends □Random □Remission □Other
9.       Premonitory Symptoms (you experience one or more of these symptoms before onset of headache):
         □Heightened feeling of wellness □Difficulty concentrating          □Increased appetite
         □Hyperactive                    □Sensitive to light                □Decreased appetite
         □Extremely talkative            □Sensitive to sound/noise          □Feeling cold
         □Depressed feeling              □Sensitive to odors                □Diarrhea
         □Irritability                   □Difficulty with speech            □Constipation
         □Feeling sluggish               □Excessive yawning                 □Extremely thirsty
         □Drowsy                         □Neck stiffness                    □Increased urination
         □Restless                       □Food cravings                     □Fluid retention
         □Dizziness                      □Weakness                          □Other: ______________
                                                                            □Other: ______________
10.      Current Pattern:       □Sudden □Rapid      □Gradual □Varies
         Time of day:           □Morning □Afternoon □Evening □Night
                                □Awakens from sleep □Varies
         Are they more frequent:
                             □Weekends      □Weekdays □Vacation
                             □Seasonal      □Spring □Summer □Fall □Winter
11.      Associated Symptoms:
         □Nausea                       □Increased urination                 □Increased appetite
         □Vomiting                     □Sore/stiff neck                     □Decreased appetite
         □Sensitive to:                □Ringing in the ears                 □Eye-tearing [Rt Lt Both]
            □Light                     □Blurred vision                      □Nose congested [Rt Lt Both]
            □Sounds                    □Anxiety                             □Eye-redness [Rt Lt Both]
            □Odors                     □Irritability                        □Drooping eyelid [Rt Lt Both]
         □Diarrhea                     □Concentration problems              □Change in pupil [Larger Smaller]
         □Constipation                 □Memory problems                     □Sensation of sand in eye [Rt Lt Both]:
         □Insomnia                     □Confusion                           □Other:         _________

12.      Aura: Visual (Do you have these symptoms before your headache begins?)
         □Blurry vision              □Loss of vision in one eye       □Tunnel vision
         □Flashing lights            □Loss of vision on one side      □Double vision
         □Zigzag lines               □Total blindness                 □Other:
      Do the symptoms spread?    □Yes-spreads slowly □No-begins all at once
                                                                                                              3
      The visual symptoms start: □before headache pain □during headache pain      □both before and during
      The visual symptoms last a total of: _______________.
      How long does the aura last before the head pain starts? ________________
      How long does the aura and head pain last altogether? _________________
      If you have more than one symptom, do they happen: □One after the other or     □All at once?
      Do you have a visual aura without headache pain? □Yes □No

13.      Aura: Sensory
         □Numbness/tingling                   □Light headedness                 □Unable to speak
          [__Right __Left __Both]             □One-sided weakness               □Other:______________
         □Dizziness/unsteadiness              □General weakness                 □Other:______________
         □Vertigo                             □Speech difficulty
      Does the sensory aura spread? □Yes-spreads slowly □No-begins all at once
      The sensory aura starts: □before headache pain □during headache pain □both before and during
      The sensory aura altogether lasts: ____________________.
      How long does the aura last before the onset of head pain? _________________
      How long does the aura and head pain last, if both occur at the same time? __________________
      If you have more than one symptom, do they happen: □One after the other or □All at once?
          Do you experience sensory aura without headache pain? □Yes □No

14.      Provoking Factors: (things that bring on a headache)
           Food/beverage:   □Fasting □Chocolate □Caffeine □Nitrates □MSG
             □Alcohol beverages________________ □Wine: [□Red □White] □Other:_____________
           Physical exertion:      □ During exercise □After exercise
           Hormonal: Menses: □Before □During □After
                      □Pregnancy □Menopause □Ovulation
           Stress: □Work □Home □Family □Spouse □Other:________________________________
           Environmental: □Allergies □Weather changes □Altitude □Sunlight □Other:____________
           Sleep: □Lack of sleep □Too much sleep □Change in wake/sleep
           Specific Activity: □Cough □Sneezing □Straining □Chewing □Sexual intercourse □
         Orgasm
           Position: □Bending □Standing    □Lying down
           Other Triggers:

15.      Activity that worsens headache:
         □None
         □Walking
         □Climbing steps
         □Exercise
         □Other:
                                                                                                            4
16.      Relieving Factors:
         □Lying down
         □Hot compress
         □Keeping active/Pacing
      □Dark quiet room
      □Cold compress
      □Standing
□Massage
□Pregnancy
□Other:_____________
17.   What are you currently taking to treat your headaches (Please list all medication, including
frequency and number of tablets):

Medication        Dose in milligrams    # of times taken per day   # of times taken per week

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________




                                                                                                     5
Headache History #2 (if you only have 1 headache type, please skip to page 9)
     Briefly describe headaches here:




1.      Onset Of First Headache:
        Headaches started ____ years ago.     I was: _____ years old.

2.      Precipitating Event (what provoked you first headache):
               □None known                         □Injury
               □Menarche (first period)            □Pregnancy
               □Other:
3.      Have your headache become more frequent or severe since the onset? Briefly describe here:




4.      Location of Pain:
        □Temples (temporal)                              □Eye
        □Back of head (occipital)                        □Ear
        □Side of head (parietal)                         □Neck
        □Front of head (frontal)                         □Jaw
        □Around head (holocranial)                       □Other:________________________
5.      Sidedness:                                      Changes Sides:
        □Right-sided                                    □Between attacks
        □Left-sided                                     □During Attacks
        □Both Sides       □Varies                       □Both between and during
6.      Pain Characteristics:
        □Throbbing/Pulsing                              □Pressure
        □Achy                                           □Burning
        □Tight                                          □Searing
        □Dull                                           □Shooting
        □Stabbing                                       □Other_________________
7.
     (a) Severity: (How bad is the pain on a scale of 0 to 10: where 0 is no pain and 10 is the worst)
         Lowest and highest level of pain for this headache: Low_____ to High ______
         Usual severity of this headache type: ________
                                                                                                         6
         Worse with menses?           □Yes □No
      (b) Headache disability during or after an attack:
          □Normal activity
          □Slight decrease in function
          □Moderate decrease in function
          □Severe decrease in function
          □Confined to bed
9.    Duration: (How long do they last?)
Lasts ___minutes ___hours ___days (with medication) | How often does it recur within 24 hrs?____%
Lasts ___minutes ___hours ___days (without medication) | How often does it recur within 24 hrs?___%
      □Headaches are continuous
10.   Frequency: (the number of attacks)
      ____#/day ____#/week ____#/month ____# per year ____# of lifetime attacks ____continuous
                Are they increasing in frequency?    □Yes □No
      (a) How many days in the last month did you experience headaches? (This includes all days of head or
          facial pain whether it be mild, moderate, or sever in intensity)
          _________days per month

      (b) Based on your answer to question (a), how many of these days are your headaches moderate to severe
          in intensity? (For example, you may experience 20 days of headache per month, of which only 10 are
          moderate to severe in intensity)
          _________days per month

      (c) Are you ever HEADACHE FREE?      □Yes □No
         □Pregnancy □Vacation       □Weekends □Random □Remission □Other
11.      Premonitory Symptoms (you experience one or more of these symptoms before onset of headache):
         □Heightened feeling of wellness □Difficulty concentrating          □Increased appetite
         □Hyperactive                    □Sensitive to light                □Decreased appetite
         □Extremely talkative            □Sensitive to sound/noise          □Feeling cold
         □Depressed feeling              □Sensitive to odors                □Diarrhea
         □Irritability                   □Difficulty with speech            □Constipation
         □Feeling sluggish               □Excessive yawning                 □Extremely thirsty
         □Drowsy                         □Neck stiffness                    □Increased urination
         □Restless                       □Food cravings                     □Fluid retention
         □Dizziness                      □Weakness                          □Other: ______________
                                                                            □Other: ______________
12.      Current Pattern:      □Sudden □Rapid      □Gradual □Varies
         Time of day:          □Morning □Afternoon □Evening □Night
                               □Awakens from sleep □Varies
                                                                                                             7
         Are they more frequent:
                             □Weekends      □Weekdays □Vacation
                             □Seasonal      □Spring □Summer □Fall □Winter
13.      Associated Symptoms:
         □Nausea                       □Increased urination                □Increased appetite
         □Vomiting                     □Sore/stiff neck                    □Decreased appetite
         □Sensitive to:                □Ringing in the ears                □Eye-tearing [Rt Lt Both]
            □Light                     □Blurred vision                     □Nose congested [Rt Lt Both]
            □Sounds                    □Anxiety                            □Eye-redness [Rt Lt Both]
            □Odors                     □Irritability                       □Drooping eyelid [Rt Lt Both]
         □Diarrhea                     □Concentration problems             □Change in pupil [Larger Smaller]
         □Constipation                 □Memory problems                    □Sensation of sand in eye [Rt Lt Both]:
         □Insomnia                     □Confusion                          □Other:         _________

14.      Aura: Visual (Do you have these symptoms before your headache begins?)
         □Blurry vision              □Loss of vision in one eye       □Tunnel vision
         □Flashing lights            □Loss of vision on one side      □Double vision
         □Zigzag lines               □Total blindness                 □Other:
      Do the symptoms spread? □Yes-spreads slowly □No-begins all at once
      The visual symptoms start: □before headache pain □during headache pain      □both before and during
      The visual symptoms last a total of: _______________.
      How long does the aura last before the head pain starts? ________________
      How long does the aura and head pain last altogether? _________________
      If you have more than one symptom, do they happen: □One after the other or     □All at once?
      Do you have a visual aura without headache pain? □Yes □No

15.      Aura: Sensory
         □Numbness/tingling                   □Light headedness                 □Unable to speak
          [__Right __Left __Both]             □One-sided weakness               □Other:______________
         □Dizziness/unsteadiness              □General weakness                 □Other:______________
         □Vertigo                             □Speech difficulty
      Does the sensory aura spread? □Yes-spreads slowly □No-begins all at once
      The sensory aura starts: □before headache pain □during headache pain □both before and during
      The sensory aura altogether lasts: ____________________.
      How long does the aura last before the onset of head pain? _________________
      How long does the aura and head pain last, if both occur at the same time? __________________
      If you have more than one symptom, do they happen: □One after the other or □All at once?
          Do you experience sensory aura without headache pain? □Yes □No

16.      Provoking Factors: (things that bring on a headache)
           Food/beverage:□Fasting □Chocolate □Caffeine □Nitrates □MSG
             □Alcohol beverages________________ □Wine: [□Red □White] □Other:_____________
                                                                                                            8
        Physical exertion:     □ During exercise □After exercise
        Hormonal: Menses: □Before □During □After
                   □Pregnancy □Menopause □Ovulation
        Stress: □Work □Home □Family □Spouse □Other:________________________________
        Environmental: □Allergies □Weather changes □Altitude □Sunlight □Other:____________
        Sleep: □Lack of sleep □Too much sleep □Change in wake/sleep
        Specific Activity: □Cough □Sneezing □Straining □Chewing □Sexual intercourse □
       Orgasm
        Position: □Bending □Standing      □Lying down
        Other Triggers:

17.    Activity that worsens headache:
       □None
       □Walking
       □Climbing steps
       □Exercise
       □Other:
18.    Relieving Factors:
       □Lying down                       □Dark quiet room               □Massage
       □Hot compress                     □Cold compress                 □Pregnancy
       □Keeping active/Pacing            □Standing                      □Other:_____________
19.   What are you currently taking to treat your headaches (Please list all medication, including
frequency and number of tablets):

Medication       Dose in milligrams       # of times taken per day   # of times taken per week

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________


                                                                                                     9
_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________




                                                                                  1
                                                                                  0
              Part 1: Please circle any medicines that you have taken for your headache

Ativan                              Limbitrol                         Toprol XA (metoprolol)
Botox                               Lithium                           Trigger point injections
Buspar                              Luvox                             Trileptal
Calan (verapamil, verlan,           Magnesium                         Triavil
isoptin)                            Melatonin                         Valium (diazepam)
Cardizem (diltiazem)                Methergine                        Vitamine B2 (Riboflavin)
Cataflam (diclofenac                Migralief                         Vivactil
potassium)                          Nardil                            Wellbutrin
Catapres (clonidine)                Navane (thiothixene)              Xanax (alprazolam)
Celebrex                            Never blocks                      Zanaflex
Celexa                              Neurontin                         Zoloft
Clinoril (sulindac)                 Norpramin (desipramine)           Zonegram
Coenzyme Q                          Norvasc (amlodipine)              Zyban
Corgard                             Pamelor (nortriptyline)           Zyprexa
Cymbalta                            Parafon Forte
                                                                      Namenda/Memantine
Depakote                            Parnate
                                                                      Amantadine
Dilantin (phenytoin)                Periactin
Effexor                             Paxil                             Singular
Elavil (amitriptyline)              Plendil (felodipine)
Feverfew                            Procardia (nifedipine)
Flexeril                            Prozac
Gabitril                            Remeron
Haldol                              Risperdal
Imipramine                          Sansert
Inderal (propanolol)                Seroquel
Indocin (indomethacin)              Serzone
Keppra                              Sinequan (doxepin)
Klonopin (clonazepam)               Tegretol (carbamazepine)
Lamictal                            Tenormin (atenolol)
Lexapro                             Tofranil
Librium                             Topamax

                                                                                                 1
                                                                                                 1
            Part 2: Please circle any medications that you have taken for your headache
Advil (ibuprofen)                  Flexeril                          OxyContin
Aleve                              Frova                             Parafon Forte
Amerge                             Haldol                            Percocet
Anaprox (naproxen sodium)          Hydrocodone                       Percodan
Antivert (meclizine                Imitrex tabs                      Phenergan (promethazine)
hydrochloride)                     Imitrex nasal spray               Phrenilin
Arthrotec                          Imitrex injections                Prednisone (prednisolone)
Aspirin                            Indocin (indomethacin)            Reglan (metoclopramide)
Axert                              Klonopin (clonazepam)             Relafen (ketoprofen)
Bellergal                          Lortab                            Relpax
Benadryl (diphenhydramine)         Maxalt                            Robaxin
Cafergot                           Medrol Dose Pak                   Skelaxin
Celebrex                           Methadone                         Soma
Celexa                             Methergine                        Stadol
Clinoril (sulindac)                Medrin                            Talwin
Codeine                            Migralief                         Thorazine (chlorpromazine)
Compazine (prochlorperazine)       Migranal                          Tigan
Davocet                            Morphine                          Toradol (ketorolac)
Daypro                             Motrin (ibuprofen)                Tylenol
Decadron (dexamethasone)           MS Contin                         Valium (diazepam)
Demerol                            MSIR                              Vicodin
DHE                                Naprelan                          Vicoprofen
Dilaudid                           Naprosyn                          Vioxx
Duragesic patch                    Navane (thiothixene)              Vistaril
Excedrin                           Nembutal                          Voltaren (diclofenac)
Feldene                            Norflex                           Wigraine
Feverfew                           Norgesic                          Xanax (alprazolam)
Fioricet                           Nubain                            Zanaflex
Fioricet with codeine              Orudis                            Zofran
Fiorinal                           Oruvail                           Zomig
Fiorinal with codeine              Oxy IR/Oxycodone                  Zyprexa

                                                                                                 1
                                                                                                 2
Previous Treatments and testing:
     1.    Previous Treatments (Please give name of provider, date, type of treatment and if it helped)

           □Primary care provider_______________________________________________________
           □Neurologist_______________________________________________________________
           □Otolaryngologist (ENT) _____________________________________________________
           □Dentist/dental______________________________________________________________
           □Chiropractor_______________________________________________________________
           □Ophthalmologist____________________________________________________________
           □Psychiatrist/psychologist_____________________________________________________
           □Biofeedback/relaxation_______________________________________________________
           □Physical therapy____________________________________________________________
           □Massage__________________________________________________________________
           □Acupuncture/acupressure_____________________________________________________
           □Herbal/homeopathic medicine_________________________________________________
           □Other: ___________________________________________________________________

     2.    Previous Tests (Please give data and results)
            □Head MRI                                                 □EEG
            □MRA/MRV                                                  □Lumbar puncture
            □Cervical MRI                                             □EKG
            □Lumbar spine MRI                                         □EMG
            □Head CT                                                  □Sleep study
                                                                      □Other:_____________________




                                                                                                          1
                                                                                                          3
Past Medical History
 1.   General Health:     □Excellent □Good □Fair □Poor
 2.    Have you had any of the following medical problems?
   □Diabetes                        □Arthritis                         □Ulcers/gastrointestinal
   □Hypertension                    □Cervical neck/spine problems      problems
   □Heart Disease                   □Skin problems                     □Kidney/renal disease
   □Stroke/transient ischemic       □Cancer                            □Infectious disease
   attack                              Type:________________              Type:________________
   □Seizures/epilepsy               □Hepatitis/liver disease           □Gynecological problems
   □Head injury                     □Deep vein thrombosis/phlebitis    □Psychiatric
   □Ear, nose, and throat           □Thyroid disease                   □Hospitalizations (See Below)
   problems                         □Pulmonary disease                 □Other:________________
   □Dental problems                 □Asthma
 3.   Have you ever been hospitalized or had surgery? (List reason, date, hospital)

  Reason for Hospital Stay                      Date                                 Hospital
_________________________                 _________________                   ______________________
_________________________                 _________________                   ______________________
_________________________                 _________________                   ______________________
_________________________                 _________________                   ______________________
_________________________                 _________________                   ______________________




 4.   Menstrual History
      Menarche (age of onset):_________         Are you still menstruating?     □Yes □No
      Last menstrual period:___________     Menses occur monthly?               □Yes □No
      Cycle length:__________________       If not monthly, every________________________
      Character:____________________        Reason for menopause:______________________
      Premenstrual symptoms:__________________________________________________________


                                                                                                   1
                                                                                                   4
     5.   Obstetrical History
          Total pregnancies:________________                      □Induced abortions____________
          □Full term babies__________                             □Miscarriage/Spontaneous
          □Premature________                                          abortions___________
          □Living__________

6.        I get ____hours of sleep per night.
          Check all that apply:

          □I have no trouble falling asleep              □I wake up during the night or early morning for no
          □I have difficult falling asleep                  apparent reason
          □I have trouble staying asleep                 □I snore or have sleep apnea
          □I sleep too much                              □My headache awakens me
                                                         □I wake up with a headache
7.        Craniofascial Pain: (check all that apply)
      □ I have jaw pain when I chew □ I have jaw pain when opening wide □ I have ear pain
□ I have jaw pain in the morning □ I clench my teeth □ I wear a “mouth guard”

8.        HEADACHES EFFECT ON ABILITY TO FUNCTION: (Do your headaches affect?)
          Record number of days missed per month of work/school and or social and family activities
          □Work productivity              □School productivity             □Social/Family activities
          ____#/days/month missed         ____#/days/month missed          ____#/days/month missed




9.     Please answer the following questions about ALL your headaches you have had over the last 3
months. Select your answer in the box next to each question. If a single headache affects more than one
area of your life (e.g., work and family life) it is counted more than once. Select zero if you did not
have the activity in the last 3 months.
   1. On how many days in the last 3 months did you miss work or school because your
       headaches?_______
   2. How many days in the last 3 months was your productivity at work or school reduced by half or more
       because of your headaches? _______
       (Do not include days you counted in question 1 where you missed work or school.)
   3. On how many days in the last 3 months did you not do household work because of your
       headaches?_______
   4. How many days in the last three months was your productivity in household work reduced by half of
       more because of your headaches? ________
       (Do not include days you counted in question 3 where you did not do household work.)

                                                                                                          1
                                                                                                          5
   5. On how many days in the last 3 months did you miss family, social or leisure activities because of
      your headaches? ___________



Review of Systems:
      Have you been having any of the following symptoms not associated with your headache?

      □Fever                               □Shortness of breath                  □Tremors
      □Fatigue                             □Nausea                               □One-sided weakness
      □Double vision                       □Constipation                         □Loss of consciousness
      □Flashing lights                     □Abdominal pain                       □Difficulty falling asleep
      □Obstructed vision                   □Frequent urination                   □Difficulty staying asleep
      □Tearing                             □Irregular periods                    □Anxiety
      □Blurry vision                       □Neck pain                            □Recent weight loss
      □Congestion                          □Muscle soreness                      □Recent weight gain
      □Ringing in the ear                  □Rash                                 □Heat or Cold intolerance
      □Chest pain                          □Cold hands and feet                  □Bruise easily
      □Rapid heartbeats                    □Shakiness                            □Hay fever symptoms
Social History:
      Living in:    □home □apartment            □other:_____________
      Living in household: _____# of people      _____# of children    _____# of children <18
      Education:  □Some high school □HS graduate or GED □Some college □College degree
                  □Post graduate school □Grade________ □Other:_________________
      Employment Status: □Part-time □Full-time □Retired □Disability □Other:__________
                          If disabled, why?_______________________________________
      Type of work:________________________          Occupation___________________________
Risk Factors:
      I drink or drank: #_____Alcoholic beverages per    □day         □week □month
              Year began:_________       Year stopped________
      Drug use:       □marijuana □cocaine/crack □heroin □other:___________________
               Year began:_________        Year stopped________
      Previous history of substance abuse:_________________________________________________
   Past or current smoking history:                           Year you stopped smoking:_________
              I smoke/d    _______ Cigarettes per    □day □week □month
              I smoke/d    _______ Cigars per        □day □week □month
              I drink      _______ Caffeinated beverages (coffee/tea/cola) per       □day □week
              I use seatbelts regularly:   □Yes □No
                                                                                                           1
                                                                                                           6
Lifestyle Factors:                                                          What type of exercise?__________
       Do you exercise?    □No □Yes _______X a week                         ____________________________
       Are you on any special diet? □No □Yes                                ____________________________
                                                                            ____________________________
       Any recent weight loss/gain? □No □Yes
       Describe diet or weight change:_____________________________________

Family History:
       Do you know of any blood relative who has had:

       □Heart disease                                            □Asthma
       □Hypertension                                             □Cancer
       □Stroke                                                   □Diabetes
       □Headache (migraine, cluster)                             □Alcohol/psych disease (depression)
       □Neurologic disease (seizures,                            □Liver disease
       Alzheimer’s)                                              □Thyroid disease
       □Arthritis
       Please explain:_____________________________________________________________________
       Family members with history of recurrent headaches: ______________________________________
       If alive, give age and current health status (good/fair/poor)
       If deceased, give age and cause of death

              Father__________________________             Spouse__________________________
              Mother_________________________              Children_________________________
              Siblings_________________________                    _________________________

                                             Medication List
List of medications, including over the counter medications: (THIS IS A REQUIRED AND VERY
IMPORTANT THAT YOU LIST ALL OF YOUR MEDICATIONS. “In my records/computer” and
“same as last visit” are not acceptable answers). DR. NAPCHAN REQUIRES YOU TO INCLUDE A
LIST OF ALL OF YOUR MEDICATIONS. IF YOU CANNOT GIVE AN ACCURATE LIST,
PLEASE BRING IN ALL YOUR MEDICATIONS TO THE APPOINTMENT.

Please list ALL medications currently taken; include over the counter medications (such as Tylenol, advil,
Excedrin, etc.), herbs, supplements, and vitamins.

           a. In Column “A”, please write each medication you use
           b. In Column “B”, please write the number of milligrams of the medication you take
           c. In Column “C”, write the number of times you take each medication per day. (i.e. 1 pill 2
              times/day)

             “A”                        _________________________            _________________________
      Medication Name                   _________________________            _________________________


                                                                                                             1
                                                                                                             7
_________________________                _______________mg                _________________________
_________________________                _______________mg                _________________________
_________________________                _______________mg                _________________________
_________________________                _______________mg                _________________________
_________________________                _______________mg                _________________________
_________________________                _______________mg                _________________________
_________________________                _______________mg                _________________________
_________________________                _______________mg                _________________________
_________________________                _______________mg                _________________________
_________________________                _______________mg                _________________________
_________________________                _______________mg                _________________________
_________________________                _______________mg                _________________________
_________________________                _______________mg                _________________________
_________________________                _______________mg                _________________________
             “B”                                  “C”                     _________________________
     Dose in Milligrams                 # of Time Taken per Day           _________________________
    _______________mg                _________________________
    _______________mg                _________________________
    _______________mg                _________________________
    _______________mg                _________________________


Do you have any allergies to any medications? Please describe your allergies below.

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________


You can use this space to describe anything you feel is important that was not covered in this
questionnaire.




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_______________________________________________________________________________________

Patient’s signature____________________________________   Date:_______________________

History reviewed:   □No changes    □Additions as noted
Physician’s signature__________________________________   Date:_______________________




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