Headache Questionnaire
Name Today’s Date
Date of Birth: Contact Number:
- Describe the pain sensation and indicate where it starts and moves
- How severe is the pain on a score 0 – 10? Please indicate how it varies.
- What is the impact on your life on a score of 0 -10?
- When and how did it start?
- What brings it on or makes it worse?
- What abolishes the pain or makes it easier?
- What have you tried to ease the pain? How well did that work for you?
- Does anything else happen around the time you get the pain?
- How often do you get the pain?
- How long does it last?
- Since it started, how has the pain altered?
- When is the pain at its worst and when at its best?
- Have you had episodes of pain like this before?
- Please express any opinions or secret fears that have been suggested or crossed your mind as the cause of the pain.
- Do you know of have you heard of anyone with a pain like yours?
- What are your hopes from today’s consultation?
17 Is there anything else I should know?
Bernard Shevlin
b.shevlin02@gmail.com