Head-Pain review questionnaire
For Headache and Migraine sufferers. You must read all details carefully.
This questionnaire is not a substitute for professional consultation, and is only intended as a supplementary document to provide health professionals with relevant diagnostic information.

This questionnaire should be printed and taken to your doctor or health professional (see also our Practice directory of relevant health professionals at www.headache.com.au)

In some cases- a case review & referral recommendation by www.headache.com.au can be performed (Fees apply)
email completed form to: info@headache.com.au
Sex    
Firstname Address
Surname City / Suburb
Date of Birth State / Postcode
Phone Country
Email
Do you require your case to be reviewed by us?  
Current Medical and Head-Pain History:
List the 3 most recent health specialists you have seen, their diagnosis, treatments & timeline, treatment outcomes.
Profession Diagnosis Treatment(s) Treatment timeline Outcome/result
  ie:Medical / GP   Tension headache   Panadeine   3 months   Pain relief only
Other Past Medical History:
List all Previous and Current Medical Conditions
Ie:Previous Diagnoses/ Medications/ blood pressure/ metabolic/ cancers/ illnesses/ trauma/ accidents etc
Note: For the questions below, please limit your response to under 250 characters
Q 1: How long ago did you first notice your head-pain (earliest memories)?
Q 2: How has your head-pain changed since?
Q 3: How often do you currently have head-pain: Ie:twice per week/ once per month/ episodically/ clusters/ average twice per six weeks etc.
Q 4: Where in your head does the pain occur: Ie:Temples/ Forehead/ Top of Head/ Face/ Behind eye / Around eyes/ One sided / Both sides/ Jaw / Hatband …etc
Q 5: How would you describe the pain: Ie: pounding/ sharp/ boring/ burning/ tightness/ aching/ alternates between…. and ….:
Q 6: Does the pain begin at any particular time (of day/ year/ menstrual etc)
Q 7: What aggravates your Head-Pain?
Q 8: What relieves your Head-Pain?
Q 9: Other Relevant Factors….. Ie:Heat/ Dehydration/ Weather/ Allergies etc
Q 10: Have you had your eyes tested?
Q 11: Do you wear spectacles/ corrective lenses?
Q 12: When were your eyes last tested?
Q 13: Have you had any Orthodontic/ Corrective Dental treatments?
Q 14: Does your jaw click or lock?
Q 16: Do you clench your teeth or gring?
Q 17: Have you had a regular Medical Check-up lately:
Q 18: Blood Pressure:
Q 19: Blood tests:
Q 20: Do you have any ongoing ear, sinus, nose, throat problems:
Q 21: Have you seen an Ear Nose and throat specialist:
Q 22: Have you seen a Neurologist for your HeadPain or any other condition(s)
Q 23: Have you had any Musculo-Skeletal Diagnoses by a Chiropractor, Osteopath, Physiotherapist etc(neck / jaw / back probs)
Q 24: What scans have you had taken in the last five years and what were the results:
Q 25: Have you had any Blood tests or other relevant tests for your Head-Pain
Q 26: Do you suffer any of the following (if so, please select)
Q 27: Do you drink coffee/tea/ chocolate/other beverages:
Q 28: Do you skip meals:
Q 29: Are you a ‘sweet-tooth’:
Q 30: Do you eat sweets and lollies often:
Q 31: Do you use sugar substitutes/ diet drinks and foods:
Q 32: Do you eat much fast food, savoury foods, processed foods, deli, smoked and cured foods:
Q 33: Do you consume much wine/ chocolate / cheese:
Q 34: Do you sleep on your stomach:
Q 35: Pillow thin or thick /foam or feather:
Q 36: Do you consume alcohol:
Q 37: What are your hobbies: (ie:reading in bed/ sewing etc)
Q 38: What sports do you play:
Q 39: What type of work do you do:
Q 40: Workstation: mostly desk/ up and down all day/ bench/ standing in front of machinery etc
Q 41: Workstation: have you ever had you workstation setup checked for its ergonomics:
Q 42: Does or has anyone else suffered from Head-Pain in your family:
Q 43: Are your Head-Pain episodes related to your menstrual cycle:
Q 44: Are you taking the contraceptive pill
Q 45: Other Comments?

Thank you for filling out this questionaire.

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Regards

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