HeadacheQuestionnaire

If you intend to come to see the doctor or nurse about headache, it might help if you could print out and complete this questionnaire, and bring it along with you when you come to see your doctor.

If you are feeling Anxious or Depressed as well, it would help if you could also complete another questionnaire to bring- click here

Name............................................ Date of Birth ...........................

Tel................................................Today’s Date ...........................

1. Describe the pain. (e.g. aching, throbbing, sharp, burning, tightness)

2. How severe is it? ....................................................................

3. How can you tell when the pain is going to start?............................

4. What do you do when the pain begins?........................................

5. Does anything bring on the pain or make it worse?..........................

6. Does anything make the pain go easier?.......................................

7. Please draw in as accurately as you can, exactly where the pain starts
and mark in clearly how it spreads or moves.

8. How often do you have the pain? .............................

9. How long does it last? ......................................................

10. Do you have any other symptoms associated with the pain?
(e.g. vomiting, diarrhea, dizziness, numbness, tingling, catarrh,
hearing, vision)

11. Is it worse at any time of the day, week or month? ..........................

12. When and under what circumstances did the pain first begin?

13. Does anyone else have a problem like yours?.................................

14. Are you more depressed or worried than usual? .............................

15. Is there anything in your current lifestyle that could be
worsening things?

16. Why did you select today to have it sorted out?

17. Could you please express any opinions, theories or secret fears about
the pain?

18. Is there anything else I should know?...........................................

EXAMINATION

E.N.T. B.P. Neck Movements.
Fundi. Temp. Other.

If you are feeling Anxious or Depressed, it would help if you could also complete another questionnaire to bring- click here

(with thanks to Dr Bernard Shevlin, a GP in Stoke on Trent)