Fillable Headache Intake Questionnaire

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Headache Intake Questionnaire

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Toronto Health and Wellness Centre
Brookeld Place, Suite 3000
181 Bay Street, PO Box 818
Toronto, Ontario M5J 2T3
Tel: (416) 507-6600 Fax: (416) 507-6630
Headache Intake Questionnaire
Toronto Health and Wellness Centre
Brookfield Place, Suite 3000
181 Bay St., PO Box 818
Toronto, ON M5J 2T3
Tel: 416-507-6600 Fax: 416-507-6610
Headache Education & Prevention Program Questionnaire
Personal Information
Last Name
Given Name(s)
Home Address
City
Prov./State
Postal Code
Secondary Phone #
Email
Preferred Contact Method
Emergency Contact
Relationship
Emergency Contact Number:
Where were you born?
Marital Status
Age of children (if applicable)
Canada
Other
Single Married Common Law Divorced Widowed
Separated Long term relationship Other
Physicians and Allied Health Professionals
Name
Specialty
Phone
Fax
Current Health Problems (Attach relevant documents and test results if applicable.)
Date of Onset
Past Medical History (Attach relevant documents and test results if applicable.)
Date
Past Surgical History and Injuries (Attach medical documents and test results.)
Date
Medications and Supplements (List all prescription and supplements)
Name
Dosage
Frequency
Date Started
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
2
Do you have any medication allergies? Please list.
Family History
Mother
Father
Alive Age Deceased Cause of death
Health Concerns
Alive Age Deceased Cause of death
Health Concerns
Siblings
# of Brothers Sisters Health Concerns
Does anybody in your family have a history of… (List details – who, what age, specific condition, etc.)
Heart Disease (heart attack, stroke, heart failure, high blood pressure, etc.)
Neurologic Disease (seizures, brain tumors, epilepsy, etc.)
Migraines or other headaches?
Work History
Highest level of education
Current occupation
Currently working?
Yes On disability
No Retired
Self employed?
Hours per day?
Length of time at current employer
Stress level
Yes
No
Low Medium
High Extreme
LIFESTYLE HEALTH BEHAVIOURS
How would you rate your health in general? Excellent □ Good □ Average □ Poor □
How many hours of sleep do you get each night? ___________________
Sleep Questions:
Do you have problems falling asleep Yes □ Problems staying asleep Yes □ No □
Do you eat breakfast each morning? Yes □ No □
Eating Behaviours:
Do you eat lunch each day? Yes □ No □
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
3
On average, how much
caffeine do you consume
daily? (please note the
number of drinks/day)
Coffee ______
______
Tea _____________
Soft Drinks/cola/pop
Coke)_________
Are you a current smoker?
No
□
□
Yes
□
□
If yes, how much do you
smoke?
Are you an ex-smoker?
No
□
□
Yes
□
□
If yes, when did you quit?
Do you use any illicit drugs?
No
□
□
Yes
□
□
If yes, which one(s)
___________________
Have you ever had
problems with illicit
drugs?
No
□
□
Yes
□
□
If yes, which one(s)
How much alcohol do you
drink on average?
drinks per day
□
□
___
per week
□
□
___
per month
□
□
__ _
Have you ever had a
problem with
alcohol?
No
□
□
Yes
□
□
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
4
HEADACHE-SPECIFIC HISTORY
*** For each question, check all the boxes that apply to you (ie you may check more than 1 box)
ONSET
1. Did you suffer from headaches when you were younger?
□ As a child □ In my 20’s – 40’s
□ As a teenager □ In my 50’s or 60’s
When were your headaches at their worst? ________________________________________
2. When d
id
your current headache problem begin?
Headaches became a problem _______________ Months
□ Years □ ago.
3. Precipitating Event
- Was there a precipitating event or trigger for your current headache problem?
□ None known
□ Specific stress ____________________________________________________
□ Injury ____________________________________________________
□ Motor vehicle accident _____________________________________________________
□ Illness _____________________________________________________
□ Menarche (first period) □ Pregnancy
□ Birth Control Pill □ Hormone Replacement
□ Other ____________________________________________________
HEADACHE CHARACTERISTICS:
4. Frequency of headaches - On average, how often do you have headaches?
They occur __________ times each
□ Day □ Week □ Month
Are they increasing in frequency?
□ Yes □ No
They are more frequent on:
□ Weekdays □ Weekends
□ Spring □ Summer □ Fall □ Winter
5. Onset of each headache
:
Headaches typically begin:
□ Gradually □ Suddenly □ Varies
They usually begin in the:
□ Morning □ Afternoon □ Evening □ Night
How long before they reach maximal intensity? _____
□ Minutes □ Hours
6. Duration of the headaches
:
Headaches usually last (with medication) ____
□ Minutes □ Hours □ Days
Headaches usually last (without medication) ____
□ Minutes □ Hours □ Days
7. Intensity of the headaches
- How bad are your headaches?
With medication:
□ Mild □ Moderate □ Severe □ Incapacitating
Without medication
□ Mild □ Moderate □ Severe □ Incapacitating
Headaches prevent activities
□ School □ Work □ Household chores
8. Location of Headaches
- Where do you feel the pain during your headaches?
□ Left side □ Right side □ May be either side □ Both sides □ Other __________________
□ Forehead □ Temple □ Behind eye(s) □ Back of head □ Neck
9. Pain Type
- What does the headache pain feel like?
□ Pressure □ Stabbing □ Throbbing □ Other __________________________
□ Tight band □ Burning □ Dull ache
10. Headache Triggers
- Do any of the following bring on/trigger your headaches?
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
5
□ 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)
□ Menstruation
□ Exercise □ Sexual activity □ Coughing
□ Prolonged computer work □ Weather changes
□ Certain Odors □ Bright lights/sun □ Loud sounds
Other _________________________________________________________________
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
HEADACHE-RELATED DISABILITY:
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? _____________
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
6
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
7
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
8
HEADACHE-SPECIFIC QUALITY OF LIFE QUESTIONNAIRE
Please answer each of the following questions by checking the most appropriate answer (1 per question):
1. In the past 4 weeks, how often have headaches interfered with how well you dealt with family, friends and
others who are close to you?
None of the time Some of the time
Most of the time All of the time
2. In the past 4 weeks, how often have headaches interfered with your leisure time activities, such as reading or
exercising?
None of the time Some of the time
Most of the time All of the time
3. In the past 4 weeks, how often have you had difficulty performing work or daily activities because of headache
symptoms?
None of the time Some of the time
Most of the time All of the time
4. In the past 4 weeks, how often did headaches keep you from getting as much done at work or at home as you
would like?
None of the time Some of the time
Most of the time All of the time
5. In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities.
None of the time Some of the time
Most of the time All of the time
6. In the past 4 weeks, how often have headaches left you too tired to do work or daily activities?
None of the time Some of the time
Most of the time All of the time
7. In the past 4 weeks, how often have headaches limited the number of days you have felt energetic?
None of the time Some of the time
Most of the time All of the time
8. In the past 4 weeks, how often have you had to cancel work or daily activities because you had a headache?
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
9
None of the time Some of the time
Most of the time All of the time
9. In the past 4 weeks, how often did you need help in handling routine tasks such as every day household chores,
doing necessary business, shopping, or caring for others, when you had a headache?
None of the time Some of the time
Most of the time All of the time
10. In the past 4 weeks, how often did you have to stop work or daily activities to deal with headache symptoms?
None of the time Some of the time
Most of the time All of the time
11. In the past 4 weeks, how often were you not able to go to social activities such as parties or dinner with friends
because you had a headache?
None of the time Some of the time
Most of the time All of the time
12. In the past 4 weeks, how often have you felt fed-up or frustrated because of you headaches?
None of the time Some of the time
Most of the time All of the time
13. In the past 4 weeks, how often have you felt like you were a burden on others because of your headaches?
None of the time Some of the time
Most of the time All of the time
14. In the past 4 weeks, how often have you been afraid of letting others down because of your headaches?
None of the time Some of the time
Most of the time All of the time
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
10
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
11
HEADACHE DISABILITY QUESTIONNAIRE
Please indicate the number of days over the past 3 months that your headaches affected the activities
described in questions 1 to 5 below.
Questions
Number of Days
How many days in the last 3 months did you miss work or school because of your
headaches?
How many days in the last 3 months was your productivity at work or school reduced
by headaches?
How many days in the last 3 months did you not do housework bec
ause of your
headaches?
How many days in the last 3 months was your housework productivity reduced by 50%
or more because of your headaches?
How many days in the last 3 months did you miss family, social or leisure activities
because of your headaches?
A. How many days in the last 3 months (90 days) did you have a headache? ______
B. On a scale of 0 to 10 (with 0 = no pain and 10 = pain as bad as it can get), what was the
average severity of your headaches over the last 3 months? ______
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
12
Headache-Related Nutrition Questionnaire
1. Are you aware of any specific food triggers that can cause your headaches? Please list:
2. If you are aware of food triggers, how did you become aware of your triggers? Please check all that
apply, and provide detail if necessary:
□ Observation/instinct ______________________________________
□ Trial and error ______________________________________
□ By completing food/symptom diaries ______________________________________
□ Suggestion from MD, dietician, naturopath ______________________________________
□ Other (provide details) ______________________________________
3. Have you made any changes to your eating behaviours to help control your headaches?
Strictly avoid specific trigger foods (list foods): _______________________________________
Try to avoid certain trigger foods, but tend to be inconsistent (list):
______________________________________________________________________________
Reduced my caffeine intake from __________ to _____________
Changed meal frequency (provide details; how consistently?) ____________________________
Added breakfast: (yes/no; how frequent?) ___________________________________________
Improved my hydration (how much more fluid, what types?): ____________________________
4. Please describe your weight:
□ My weight has been fairly stable (within 10 lbs) in my adult life
□ My weight has increased over the years
□ My weight has gradually declined over the years
□ My weight tends to fluctuate up and down
5. Do you diet, follow weight loss programs, or visit weight loss centres (e.g. Weight Watchers, low carb, Bernstein, Fuel for Life,
Atkins, etc.)?
□ Never or almost never
□ Yes, I’ve tried a few diets, diet centres, or programs
□ Frequently. I usually try a few diets or programs each year
□ I’m constantly dieting
6. Do you currently, or have you ever tried supplements (vitamins, minerals, herbs) to help control your headaches? Please list:
SUPPLEMENT DOSE (IF KNOWN) LENGTH OF TIME TAKEN IMPACT
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
Do you engage in regular physical activity?
□ Yes □ No
Do you have access to a fitness gym? □ Yes □ No
Do you have a personal trainer/fitness coach? □ Yes □ No
□ Commercial
□ Private studio
□ Work
□ Home
□ Condominium
□ Other ………………………………………………………………..
Name/contact info (if desired):
………………………………………………………
Equipment/Facilities Available (whether currently used or not):
Cardiovascular
Strength Training
Sports Equipment/Facilities
□ Treadmill
□ Stationary Bike
□ Track
□ Elliptical
□ Other:
………………………………………
□ Free Weights
□ Machines
□ Resistance Bands
□ Physio balls
□ Other:
………………………………………
□ Squash/Tennis courts
□ Golf Course/range
□ Skiing
□ Pool
□ Other:
…………………………………..
Current Physical Activities:
Cardiovascular
Strength
Modes/Type of Training:
Modes of Training:
□ Treadmill
□ Stationary Bike
□ Walking/Jogging
□ Swimming
□ Elliptical
□ Sports (please list):
………………………….....
□ Machines
□ Free Weights
□ Other (please list):
……………………………………………………..
How many minutes per day?
□ 10 to 20
□ 20 to 30
□ 30 to 40
□ 40 to 60
□ 60+
How many minutes per day?
□ 10 to 20
□ 20 to 30
□ 30 to 40
□ 40 to 60
□ 60 +
How many times per week?
□ 1
□ 2
□ 3
□ 4
□ 5
□ 6
□ 7
□ More ………..
How many times per week?
□ 1
□ 2
□ 3
□ 4
□ 5
□ 6
□ 7
□ More ……...
Intensity:
□ High
□ Moderate
□ Low
□ HR Zones: High …………….
Low …………….
Avg …………….
□ Interval Training:
Ratio high:low ……………….
Set Routine:
□ Yes □ No
Sets …………………….…..
Reps ……………………….
Rest between sets ……….…
Sports You Participate In:
Activity
Yrs Participated
Highest Level of Competition
Current Level of Competition
□ Recreational
□ Competitive
□ Professional
□ Recreational
□ Competitive
□ Professional
□ Recreational
□ Competitive
□ Professional
□ Recreational
□ Competitive
□ Professional
□ Recreational
□ Competitive
□ Professional
□ Recreational
□ Competitive
□ Professional
□ Recreational
□ Competitive
□ Professional
□ Recreational
□ Competitive
□ Professional
13
Physical Activity Questionnaire
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
14
Psychology Questionnaire – Headache Program
STRESS MANAGEMENT:
Please describe any recent life stressors (e.g. health, relationships, financial, work)?
How do you cope with stress in your life (e.g., physical exercise, meditation, relaxation)?
How helpful are these techniques at managing your current level of stress?
Is it often hard for you to relax and unwind? Yes No
FUNCTIONAL ASSESSMENT:
In the past month have you….
Yes No
Had periods of time when you feel down or depressed?
Felt less interested in doing things you normally like to do?
Head periods of excessive energy, mood swings, increased irritability and/or loss of concentration?
Been worrying excessively about a number of things?
Felt very nervous or anxious or suddenly experienced a lot of physical symptoms (e.g., heart racing, sweating)?
Had a fear of losing control of yourself or “going crazy”?
Avoided social situations for fear of what others may think or say about you?
Been afraid of leaving your home alone, or being home alone?
Had repeated thoughts or images in your head that are difficult to dismiss?
Felt compelled to complete certain behaviours repeatedly (e.g., checking to make sure you locked the doors, washing your hands again and again,
etc.)?
Thought a lot about or relived an upsetting event from the past?
Found yourself preoccupied with food, weight or body image?
Been concerned about your use of alcohol or medication/drugs?
Have you been in therapy before or received any prior professional assistance for emotional, psychological or
relationship issues? Yes No If yes, please describe, starting with most recent/current
Dates
Duration/# of sessions
Physician/Therapist
Type of Therapy/Treatment (marriage counseling, group sessions, etc.)
Have you ever been diagnosed with a psychological condition (e.g. clinical depression)? Yes No
If yes, please describe.
Thank you for taking the time to complete this form. Your responses will be treated as private and confidential.
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
15
PATIENT OPINIONS/QUESTIONS:
1. What type of headache(s) do you think you have?
___________________________________________________________________________________
2. Do you have any specific concerns/fears about your headaches?
___________________________________________________________________________________
3. What specific questions do you have for Dr. Gladstone and the Headache Program Team?
(a)
(b)
(c)
(d)
(e)
(f)
(g)
Thank-you for taking the time to complete this important questionnaire.
The Cleveland Clinic © Copyright and Moral Rights. 1995-2009. All Rights Reserved.
Brookfield Place, Suite 3000, 181 Bay Street, Box 818, Toronto, Ontario M5J 2T3 | 416.507.6600
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Headache Intake Questionnaire

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