Chronic headaches- Questionnaire: Headache History

 

Here is a list of questions that will guide us choose the right neuromuscular treatment for you

 

  1. On a scale of 1-10 with “10” being the worst pain imaginable above the shoulders, how many mornings per week do you wake up with a “0” (zero)?
  2. On a scale of 1-10, what’s the average “number” you usually wake with?
  3. What % of your waking time do you have some degree of headache?
  4. What % of your waking time do you have a “0” (zero) without taking medications?
  5. What is your average headache pain level (1-10 scale) throughout the day?
  6. On a scale of 1-10, what is the worst pain level you experience?
  7. What time of day do you usually experience your worst headaches?
  8. How many times per week (or month) might you experience your worst pain?
  9. Where does your pain seem to originate from?
  10. How would you describe your pain? (Examples: throbbing, squeezing, pressure, dull, stabbing, shooting, etc.)
  11. Please circle the types of health care providers you’ve seen for your headaches.  MD, Neurologiste, ENT, Internist, Physical Therapist, Chiropractor, Dentist, Others:
  12. What medical tests have been performed regarding your headaches? CT scan, MRI, Xray, Blood analysis, Other:
  13. What types of procedures or treatments (including dental) have you had (for headaches)?
  14. What medication(s) do you now take to prevent your headaches?
  15. What medications have you tried to prevent your headaches?
  16. What prescribed or over-the-counter medications do you take to relieve your headaches? (and how much)

 

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