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Medical Questionnaire
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AKU ID
Date of Birth
Gender
Male
Female
Neurologist
-- Select a Neurologist --
Prof. Sokhi
Dr. Ekea
Dr. Nyambane
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General Headache Questions
1. Is the headache associated with fever?
Yes
No
2. Have you ever been treated for cancer?
Yes
No
3. Do you have any new weakness on one side of the body?
Yes
No
4. Have you lost consciousness due to the headache?
Yes
No
5. Did the headache occur or start very suddenly (in a few seconds to a minute)?
Yes
No
6. Is this the first time you are having such a headache?
Yes
No
7. If you have had a similar headache or migraine before, does the current headache feel different?
Yes
No
8. Does the headache get worse by changing position either sitting up from lying down, or lying down after sitting up?
Yes
No
9. Is the headache triggered by sneezing, coughing or exercise?
Yes
No
10. Has the headache been getting worse over time?
Yes
No
11. While experiencing the headache, do you have eye pain with automatic release of tears or drooping or swelling of the eyelids?
Yes
No
12. Are you pregnant or have you recently delivered a baby (in the past six weeks)?
Yes
No
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Characterization of Headache
1. Does the headache last between 4-72 hours if not treated or unsuccessfully treated?
Yes
No
2. Does the headache tends to be on one side?
Yes
No
3. Does the headache feel throbbing or have pulsating quality?
Yes
No
4. Is the pain intensity moderate to severe?
Yes
No
5. Does the headache causes avoidance of routine physical activity or is worsened by movement?
Yes
No
6. When the headache is occurring, is there any nausea and/or vomiting?
Yes
No
7. When the headache is occurring, is there any photophobia and phonophobia?
Yes
No
8. Is the headache preceded by aura?
Yes
No
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General Health Questions
1. Are you currently using oral contraceptive pills?
Yes
No
2. Are you trying to have, or want to have children in the near future?
Yes
No
3. Are headaches associated with Periods?
Yes
No
Lifestyle Questions
1. On average, how many hours of sleep are you getting?
-- Select a range --
1 - 4 hours
4 - 6 hours
6 - 8 hours
More than 8 hours
2. On average, how many liters of water do you drink per day?
-- Select a range --
Less than 0.5 liters
0.5 - 1.5 liters
1.5 - 2 liters
More than 2 liters
3. On average, how many cups of tea or coffee do you take daily?
-- Select a range --
0 cups
1 cup
2 cups
3 cups
More than 3 cups
4. On average, how many times a week do you exercise?
-- Select a range --
0
1
2
3
4
5
6
7
5. On an average day, what is your stress level (percentage wise)?
-- Select a range --
0-30
31-60
61-80
More than 80
6a. Do you take alcohol?
Yes
No
6b. Select which type you take most frequently
6c. What quantity (ml) per sitting?
6d. On average, how often (# of days/month)?
-- Select a range --
1-4
5-7
8-14
More than 15
7a. Do you take smoke cigarettes or use tobacco?
Yes
No
7b. If smoking, what quantity (# of sticks/day)?
-- Select a range --
0
1-5
5-10
10-15
15-20
More than 20
7c. If using tobacco, how often (average # of days/week)?
-- Select a range --
0
1
2
3
4
5
6
7
Specific Health Conditions Questions
1a. Medical conditions the patient suffers from (select all that apply)?
1b. Medical condition that patient suffers from (if not listed above)?
1c. Current medications being used for medical illness (if any)?
2. Do you have a family history of headaches?
Yes
No
3a. Are you aware of any allergies to medication you have?
Yes
No
3b. Which medication are you allergic to?
Headache and Medication History
1. On average how many times per week do you get headaches?
-- Select --
0
1
2
3
4
5
6
7
2a. Are you currently using medications for Migraine treatment?
Yes
No
2b. Select all the medication and doses
2c. Select the frequency of medication
2d. What is the effectiveness of the current medication used? (1-5, 1 being the lowest)
-- Select --
1
2
3
4
5
3a. Are you currently using or have ever used medications for Migraine prevention?
Yes
No
3b. Select all the medication and doses
3c. Select the frequency of medication
3d. What is the effectiveness of the current medication used? (1-5, 1 being the lowest)
-- Select --
1
2
3
4
5
4. Have you had any side effects from previous medications (specified)?
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