new patient questionnaire - page 1 · 2019-10-18 · new patient questionnaire - page 4 headache...

NEW PATIENT QUESTIONNAIRE -

Provider you will be seeing: Date of Appointment:

Patient Name: Date of Birth: Age:

Home Address / City / State / Zip:

Home Phone: Work Phone: Cell:

Email: Emergency Contact: Phone:

PHYSICIAN INFORMATION -

What is the name of your PRIMARY CARE PROVIDER:

Address / City / State: Phone:

What is the name your REFERRING PROVIDER (if different from above):

Address / City / State: Phone:

HEADACHE SPECIFIC QUESTIONS -

What is your biggest concern about your headaches:

Do you have sick / severe headaches: YES NO Date sick / severe headache started:

How many sick / severe headaches have you had in your life: 0-2 3-10 11-20 21-50 51-100 >100

Frequency of sick / severe headaches (per month and per year):

Were you adopted: YES NO

Does anyone in the family have headaches (migraine, sick, sinus, tension, cluster, other):

Were you ever carsick as a child: YES NO

RELATION YES NO DESCRIBE RELATION YES NO DESCRIBE

Mother Father

M. Gma P. Gma

M. Gpa P. Gpa

M. Aunts P. Aunts

M. Uncles P. Uncles

Sisters Brothers

Daughters Sons

AGE MONTH YEAR DESCRIBE

As a child less than 12 years

As an adolescent 13-18 years

As a young adult 19-30 years

As an adult over 30 years


SOME PEOPLE HAVE MORE THAN ONE TYPE OF HEADACHE -

How many days have you had a headache in the last: month: days 3 months: days 6 months: days

Visits to the ER in the last 12 months: visits

Days missed at work or school in the last month: days

On a scale of 1-10, on average, how painful are your headaches: (1= pain free, 10 = pain is unbearable)

Headache frequency, type, location, and symptoms:

MOST SEVERE HEADACHE DAILY HEADACHE OTHER HEADACHE TYPE FACE PAIN

number per year

number per month

severity (1-10)

length (hours)

-TYPE OF PAIN-

throb

stab

ache

sharp

pulsating

pressure in head

jabs & jolts

- LOCATION OF PAIN -

right

left

temples

behind eye

all over

back of neck

- ASSOCIATED SYMPTONS -

nausea

vomiting

photosensitivity (light)

phonosensitivity (sound)

smell sensitivity

aggravated by activity/movement

worse in: (morning, afternoon, or night)

effect on life: (no interference, some interference, no activity, bedridden, or emergency room)

other:


OTHER SYMPTOMS ASSOCIATED WITH YOUR HEADACHES -

Aura Symptoms

Vision: blur blindness zig zag lines spots bright flashes other:

Sensory: numbness tingling (Location: Duration: )

Brainstem: vertigo / dizziness

Speech: difficulty finding words / speech arrest

Motor: weakness in one side of face or body

Duration of aura: minutes

Onset of headache after aura: minutes

Aura before every headache: YES NO

Headache after every aura: YES NO

Aura without headache: YES NO

Other symptoms: nasal stuffing / running flushing eye lid drooping / swelling scalp tenderness

skin sensitivity neck tenderness weakness odor sensitivity sweating

pupil dilated other:

OTHER HEADACHE CHARACTERISTICS -

Does this headache wake you from your sleep: YES NO

Is your headache worse: Upright: YES NO Lying down: YES NO

Have you ever had a serious head injury with loss of consciousness: YES NO Date:

Have you had any history of mild head injury (sports, whiplash assault, etc): YES NO Date:

Have you had a recent viral illness prior to headache onset: YES NO Date / Explain:

TRIGGERS -

Diet: alcohol meat msg caffeine other:

Environment: light sound smell weather travel altitude temperature

Physical: exercise position sleep pattern sexual activity

Emotional: anger anxiety stress depression fatigue

Hormones: menstrual cycle ovulation pregnancy menopause

OTHER SYMPTONS / CHARACTERISTICS / TRIGGERS -


HEADACHE DISABILITY-MIDAS QUESTIONNAIRE -

1. How many days in the last 3 months did you miss work / school because of your headaches: days (If you do not attend work or school write “0”)

2. How many days in the last 3 months was your productivity at work or school reduced by half or more: days (Do not include days you counted in Question #1)

3. How many days in the last 3 months did you not do household work because of your headaches: days

4. How many days in the last 3 months was your productivity in the household work reduced by half or more: days (Do not include days from Question #3)

5. How many days in the last 3 months did you miss family social, or leisure activities because of headaches: days

TOTAL: days

A. How many days in the last 3 months did you have a headache: days (If a headache lasted more than 1 day, count each day)

B. On a scale of 0–10, on average how painful were these headaches: (Where 0 = no pain at all, and 10 = pain as bad as it can be)

©

PREVIOUS HEADACHE WORKUP -

PROCEDURES FOR HEADACHE -

DATE PLACE

CT scan / x-rays

MRI

blood work

eeg

lumbar puncture

sleep study

general practice / internal medicine evaluation

neurologist

chiropractor

dentist

psychologist / psychiatrist

pain clinic

physical therapist

ophthalmologist / last eye exam

other:

* ANY RADIOLOGY IMAGING PERFORMED OUTSIDE THE UNIVERSITY OF UTAH - PLEASE BRING US YOUR ACTUAL SCANS.

DATE RESPONSE

botox

nerve blocks

acupuncture

Innovative Medical Research 1997


CURRENT MEDICATIONS AND ALLERGIES -

Are you taking any prescriptions and/or non prescriptive medications (if yes, please list below): YES NO

Have you had any allergic reactions to any medications (if yes, please list below): YES NO

MEDICATION DOSE FREQUENCY

OVER-THE-COUNTER (including herbals & supplements) DOSE FREQUENCY

NAME OF MEDICATION PROBLEM


PREVIOUS SURGERIES, ILLNESSES, & ACCIDENTS -

List and describe any surgeries that you have had:

List major illnesses that you have had:

List any serious accidents or injuries that you have had:

List any prior history of depression or psychological difficulty:

DIET & EXERCISE -

Dietary restrictions / preferences:

Number of servings of fruits and vegetables per day: servings

Do you exercise: YES NO Type of exercise: Number of days of exercise per week: days

Are you overweight: YES NO If yes, by how many pounds: LBS

DATE OF SURGERY DESCRIPTION OF SURGERY

DATE OF ACCIDENT DESCRIPTION OF ACCIDENT

DATE EXPLAIN (hospitalization, outpatient treatment, etc)

DATE OF ILLNESS DESCRIPTION OF ILLNESS


FAMILY HISTORY -

Do you know of any blood relatives who has or had any of the following:

SOCIAL HISTORY -

Do you use any of the following:

Caffeine (coffee, tea, soda): YES NO If yes, number of ounces per day: OZ

Tobacco: YES NO If yes, number of cigarettes / amount of chew per day: cigarettes / chew / other

Alcohol / Beer / Wine / Liquor: YES NO If yes, number of drinks per week: drinks

Recreational / Street Drugs: YES NO If yes, please explain:

What is your marital status: single married separated divorced widow / widower

What is your current occupation: Work hours per week: HRS

What is your level of education: high school some college bachelors degree graduate degree

YES NO FAMILY MEMBER(S)

anemia

arthritis

asthma

b12 deficiency

bleeding disorder

cancer

colitis

diabetes

depression / anxiety

eye problems

heart disease / heart attack

high blood pressure

kidney disease

lupus

multiple sclerosis (MS)

obesity

seizures

stroke

thyroid problems

tuberculosis

other:


REVIEW OF SYSTEMS (If experienced within the previous 6 months, please check if “yes”) -

General / Constitutional:

weight loss (Specify: lbs) weight gain (Specify: lbs) fatigue

poor state of health (Explain):

Skin / Breast:

rash itching injection site issues breast lumps tenderness swelling

nipple discharge changes in hair growth or loss, nail changes (Explain):

Eyes / Ears / Nose / Mouth / Throat:

vertigo / dizziness lightheadedness vision changes double vision tearing blind spots

nose bleeding frequent colds dental difficulties bleeding gums neck stiffness

neck pain masses in thyroid

Cardiovascular:

chest pain palpitations / irregular heartbeat syncope / fainting edema / swelling

poor circulation / discoloration of hands & feet

Respiratory:

shortness of breath wheezing cough fever / night sweats

Gastrointestinal:

change in appetite problems swallowing indigestion / heartburn nausea / vomiting

constipation diarrhea abdominal pain

Genitourinary:

urgency frequency painful urination frequency at night number of times with kidney stones

infections change in sexual drive

Females: age of onset of menses number of pregnancies number of deliveries

number of miscarriages / abortions number of living children

Musculoskeletal:

muscle / joint pain swelling / redness of muscles or joints muscular weakness

Neurologic / Psychiatric:

numbness weakness memory / speech difficulty motor / muscular coordination problems

emotional problems anxiety depression unusual perceptions / hallucinations

Allergic / Immunologic / Lymphatic / Endocrine:

food reactions insects environmental exposures anemia bleeding tendency

previous transfusions & reactions local or general lymph node enlargement or tenderness (Location: )

frequent thirst / drinking / urination intolerance to heat or cold seasonal allergies (Explain):

Other:


DAILY MEDICATIONS TAKEN IN THE PAST TO HELP PREVENT HEADACHE -

DRUG DOSE HOW LONG EFFECT ON HEADACHE

- NONSTEROIDAL ANTIINFLAMMATORIES -

ibuprofen (Motrin, Advil)

naproxen (Naprosyn)

celecoxib (Celebrex)

piroxicam (Feldene)

diclofenac (Voltaren)

indomethacin (Indocin)

meloxicam (Mobic)

nabumetone (Relafen)

other:

- CARDIAC MEDICATIONS -

timolol (Blocadren)

nadolol (Corgard)

propranolol (Inderal)

metoprolol (Lopressor,Toprol)

atenolol (Tenormin)

verapamil (Calan, Isoptin, Verelan)

amlodipine (Norvasc)

nifedipine (Procardia)

diltiazem (cardizem)

clonidine (Catapress)

other:

- PSYCHOTROPIC MEDICATIONS -

amitriptyline (Elavil)

nortriptyline (Pamelor)

imipramine (Tofranil)

doxepin (Sinequan)

desipramine (Norpramin)

protriptyline (Vivactil)

fluoxetine (Prozac)

sertraline (Zoloft)

paroxetine (Paxil)

citalopram (Celexa)

escitaloproam (Lexapro)

venlafaxine (Effexor)

desvenlafaxine (Pristiq)

duloxetine (Cymbalta)

mirtazapine (Remeron)

fluvoxamine (Luvox)


DAILY MEDICATIONS TAKEN IN THE PAST TO HELP PREVENT HEADACHE (continued) -


trazodone (Desyrel)

nefazodone (Serzone)

bupropion (Wellbutrin)

phenalzine (Nardil)

tranylcypromine (Parnate)

aripiprazole (Abilify)

olanzapine (Zyprexa)

quetiapine (Seroquel)

risperidone (Risperdal)

ziprasodone (Geodon)

other:

- ANTISEIZURE MEDICATIONS -

valproic acid (Depakote)

gabapentin (Neurontin)

pregabalin (Lyrica)

phenytoin (Dilantin)

carbamazepine (Tegretol, Carbatrol)

oxcarbazepine (Trileptal)

topiramate (Topamax)

lamotrigine (Lamictal)

zonisamide (Zonegran)

tiagabine (Gabatril)

levetiracetam (Keppra)

other:

- MUSCLE RELAXANTS -

carisoprodal (Soma)

cyclobenzaprine (Flexeril)

methocarbamol (Robaxin)

tizanidine (Zanaflex)

baclofen (Lioresal)

orphenadrine (Norflex)

metaxalone (Skelaxin)

other:

- ANTIANXIETY AGENTS -

diazepam (Valium)

clonazepam (Klonopin)

alprazolam (Xanax)

lorazepam (Ativan)


DAILY MEDICATIONS TAKEN IN THE PAST TO HELP PREVENT HEADACHE (continued) -

What medications have worked best for you:

What medications have worked best for a family member with headache:

MEDICATIONS USED TO TREAT HEADACHE ACUTELY (as needed) -


- PAIN MEDICATIONS -

hydrocodone / apap (Lortab, Vicodin)

acetaminophen with codiene (Tylenol #3)

extended release oxycodone (Oxycontin)

extended release morphine (MS Contin, Kadian, Oramorph)

fentanyl patch (Duragesic)

methadone

tramadol (Ultram)

tapentadol (Nucyncta)

oxymorphone (Opana)

- SLEEP MEDICATIONS -

zolpidem (Ambien)

zaleplon (Sonata)

eszopiclone (Lunesta)

ramelteon (Rozerem)

chloral hydrate (Somnote)

melatonin

other:

- OTHER -

methysergide (Sansert)

cyproheptadine (Periactin)

memantine (Namenda)

DRUG DOSE EFFECTIVE NOT EFFECTIVE NUMBER OF DAYS USED PER WEEK

isometheptene / dichloralphenazone/apap (Midrin)

ergotamine (Cafergot, Wigraine)

butalbital / apap / caffeine (Fioricet) with or without codiene

butalbital / asa / caffeine (Fiorinal) with or without codiene

apap / asa / caffeine (Excedrin)


MEDICATIONS USED TO TREAT HEADACHE ACUTELY (continued) -

DRUG DOSE EFFECTIVE NOT EFFECTIVE COMMENTS

apap / codiene (Tylenol #3)

hydrocodone / apap (Lortab, Vicodin, Norco)

oxycodone (Percocet, Roxicet)

meperidine (Demerol)

morphine

hydromorphone (Dilaudid)

tramadol (Ultram)

ibuprofen (Motrin, Advil)

naproxen (Aleve, Naprosyn)

celecoxib (Celebrex)

ketorolac (Toradol) tablet

ketorolac (Toradol) injection

dihydroergotamine injection

dihydroergotamine nasal spray (Migranal)

dihydroergotamine inhaler (Levadex)

sumatriptan SQ injection (Imitrex, Sumavel)

sumatriptan nasal spray (Imitrex)

sumatriptan tablets (Imitrex)

zolmitriptan nasal spray (Zomig)

zolmitriptan (Zomig) ZMT or tab

rizatriptan (Maxalt) MLT or tab

almotriptan (Axert)

frovatriptan (Frova)

naratriptan (Amerge)

eletriptan (Relpax)

sumatriptan + naproxen (Treximet)

lidocaine nose drops

oxygen

butorphanol nasal spray (Stadol)

butorphanol injection (Stadol)

steroids (Prednisone, Medrol Dose Pack)

other:


MEDICATIONS USED TO TREAT NAUSEA AND/OR VOMITING -

What medications have worked best for you:

SUPPLEMENTS OR HERBAL PRUDCES USED FOR HEADACHE -

DRUG DOSE EFFECTIVE NOT EFFECTIVE COMMENTS

promethazine injection (Phenergan)

promethazine tablets (Phenergan)

promethazine suppositories (Phenergan)

prochlorperazine injection (Compazine)

prochlorperazine tablets (Compazine)

prochlorperazine suppositories (Compazine)

trimethobenzamide capsules (Tigan)

trimethobenzamide suppositories (Tigan)

metoclopramide (Reglan)

hydroxyzine (Vistaril)

ondansetron tablets (Zofran)

ondansetron injection (Zofran)

other:

PRODUCT DOSE EFFECTIVE NOT EFFECTIVE COMMENTS

butterbur (Petadolex)

feverfew

riboflavin (Vitamin B2)

magnesium

coenzyme Q10

fish oil

5-hydroxytriptophan (5-HTP)

St. John’s Wort

ginger

migrelief

other:


PHQ-9 TEST (Use a check mark to indicate your answer) -

Over the last 2 weeks, how often have you been bothered by the following problems?

NOT AT ALL SEVERAL DAYS MORE THAN HALF THE DAYS NEARLY EVERY DAY

Little interest or pleasure in doing things. 0 1 2 3

Feeling down, depressed, or hopeless. 0 1 2 3

Trouble falling or staying asleep, or sleeping too much.

0 1 2 3

Feeling tired or having little energy. 0 1 2 3

Poor appetite or overeating. 0 1 2 3

Feeling bad about yourself–or that you are a failure or have let yourself or your family down.

0 1 2 3

Trouble concentrating on things, such as reading the newspaper or watching television.

0 1 2 3

Moving or speaking so slowly that other people could have noticed? Or the opposite–being so fidgety or restless that you have been moving around a lot more than usual.

0 1 2 3

Thoughts that you would be better off dead or of hurting yourself in some way.

0 1 2 3

(FOR OFFICE CODING: 0 + + + = Total Score )

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get

along with other people: not difficult at all somewhat difficult very difficult extremely difficult

GAD-7 TEST (use a check mark to indicate your answer) -

Over the last 2 weeks, how often have you been bothered by the following problems?

NOT AT ALL SEVERAL DAYS MORE THAN HALF THE DAYS NEARLY EVERY DAY

Feeling nervous, anxious or on edge. 0 1 2 3

Not being able to stop or control worrying. 0 1 2 3

Worrying too much about different things. 0 1 2 3

Trouble relaxing. 0 1 2 3

Being so restless that it is hard to sit still. 0 1 2 3

Becoming easily annoyed or irritable. 0 1 2 3

Feeling afraid as if something awful might happen.

0 1 2 3

(FOR OFFICE CODING: Total Score T = + + )

*The PHQ-9 & GAD-7 tests were developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc.

END OF QUESTIONNAIRE - Thank you for your patience.

new patient questionnaire - page 1 · 2019-10-18 · new patient questionnaire - page 4 headache...

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