□ Foods (specific food triggers will be discussed later in the questionnaire)
□ Too much caffeine □ Not getting enough caffeine
□ Hunger / Skipping meals □ Alcohol □ Wine
□ Fatigue □ Too little sleep □ Too much sleep (sleeping in)
□ During stressful times □ After stress (first day of vacation, weekend, after a test)
□ Exercise □ Sexual activity □ Coughing
□ Prolonged computer work □ Weather changes
□ Certain Odors □ Bright lights/sun □ Loud sounds
11. Premonitory Symptoms - Do you experience any of the following before your headache begins?
□ Mood changes □ Personality changes □ Other ______________________________
□ Change in appetite □ Food cravings
□ Neck pain □ Fatigue □ No, I don’t experience any of these
12. Aura Symptoms - Do you ever experience any of these warning symptoms before your headache begins?
□ Bright lights / flashes of lights/ multi-colored lights (circle applicable description)
□ Zig-zag lines □ Partial loss of vision / blurry vision / blindness (circle applicable)
□ Numbness / tingling □ Paralysis
□ Dizziness or vertigo □ Upset stomach / nausea □ No I don’t have these
13. Associated Symptoms - Do you experience any of these symptoms during your headaches?
□ Nausea / upset stomach □ Vomiting
□ Bright lights/sun bothers you □ Loud sounds bother you
□ Strong smells/odors bother you
□ Dizziness / lightheadedness / vertigo (circle applicable description)
□ Numbness or tingling
□ Increased sensitivity of Scalp / Hair / Ears
□ Eye tears □ Runny or stuffy nose
□ Difficulty concentrating □ Mood changes / irritability
14. Alleviating Factors - During a headache, what makes you feel the most comfortable?
□ Lying down / sleeping □ Being in a dark quiet room
□ Keeping physically active □ Pacing back-and-forth
□ Massage your head □ Tying something around your head
□ Cold pack on your head/neck □ Hot pack on your head/neck
15. Effect of headaches on ability to function:
a) During Milder headaches: b) During moderate or severe headaches:
□ I am able to function normally □ I am able to function normally
□ My ability to function is slightly decreased □ My ability to function is slightly decreased
□ My ability to function is severely decreased □ My ability to function is severely decreased
□ I am totally bedridden □ I am totally bedridden
16. Doctor Visits for Headache
– How many times would you estimate that you have visited the following because of your
headaches in the past 1 year?
□ Family physician _________________
□ Walk-in clinic _________________
□ Emergency department _________________
17. How many days of work or school have you missed in the past 1 year because of headaches? _____________
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