People with headache
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Questionnaire
1) About yourself
1.1) Your attention to the assessment
first attention
follow-up (please give information continued from the last assessment)
1.2) Gender
male
female
1.3) Age (years)
1.4) Weight (kilograms)
1.5) Height (centimeters)
1.6) Note (generally no need to specify)
2) About this type of your headache
never had this type of headache before; this is the first attack. (If it still persists, how long has it lasted?)
have had this type of headache before; the first attack occurred less than 3 months ago.
have had this type of headache before; the first attack occurred more than 3 months ago.
3) Other types of headaches unlike this type
no, never had other types
yes, have had other types
(if yes, please do not consider them in this assessment)
4) Age at first attack of this type of headache
not more than 50 years old (please specify)
more than 50 years old (please specify)
5) When headache attacks, how does it build up?
pain gradually increases
pain peaks rapidly over minutes
pain peaks suddenly in less than 1 minute
6) Pain intensity of this type of headache
mild (does not interfere with usual activities)
moderate (prevents some usual activities)
severe (prevents all activities)
this attack is the most severe ever
7) Side of the head that pain (usually) affects
right side
left side
side shifting, with similar frequency on each side
both sides at the same time or all over the head
midline area
8) Location of pain
8.1) Pain starts at
around the eye(s)
forehead
temple(s)
back of the head
all over the head
neck
other
8.2) Pain spreads to…(if any)
9) Pain (usually) feels like
pulsating / throbbing
pressing / tightening (non-pulsating)
stabbing / sharp
burning
pain only over the scalp
other
10)
During headache
, pain is made worse by (may choose more than one)
walking or climbing stairs
coughing
sneezing
straining
waking up in the morning
lying down
made worse by other
not made worse by walking or climbing stairs
11)
During headache
, associated symptoms are present (may choose more than one)
mild nausea
moderate to severe nausea
vomiting
sensitive to light (during headache, prefer to be in dark room)
sensitive to noise (during headache, prefer to be in quiet room)
sensitive to touch on hair or skin
red eye
(
right
left
)
teary eye
(
right
left
)
stuffy nose
(
right
left
)
runny nose
(
right
left
)
swollen eyelid
(
right
left
)
droopy eyelid
(
right
left
)
facial sweating
(
right
left
)
facial flushing
(
right
left
)
fullness in ear
(
right
left
)
sense of restlessness
other symptoms during headache
no associated symptoms during headache
12)
If no medication
, how long does each attack last?
less than 1 minute
1 - 30 minutes
31 minutes - 3 hours
4 hours - 3 days
4 - 7 days
or specify (may add other details)
Note
: If relieved after sleeping, the time of awakening is considered the ending time of pain. If waking up in the morning with persisting pain, the headache is considered continuous from the day before.
13) Total number of attacks of this type that you have ever had
fewer than 5 attacks
5 - 9 attacks
10 - 19 attacks
20 attacks or more
14) In each month, if the days of headache are fewer than 15 days, skip to question 15.
14.1) Days of headache in each month
every day in each month
nearly every day (at least 15 days per month)
14.2) How long has such frequent headache been present?
less than 3 months
more than 3 months
15) Visual symptoms before or during headache
15.1)
Within an hour before
or
during headache
, following symptoms have occurred. (may choose more than one)
seeing flashing light
seeing unusual view
blurred or blind spot
never (if never, skip to question 16)
15.2) The above visual symptoms last for
less than 5 minutes
5-60 minutes
more than 1 hour
16) Sensory symptoms on body, face, or tongue before or during headache
16.1)
Within an hour before
or
during headache
, sensory symptoms have occurred as (may choose more than one)
pins and needles (tingling sensation)
numbness (loss of sensation)
never (if never, skip to question 17)
16.2) The above sensory symptoms usually occur on
right side
left side
both sides
16.3) The above sensory symptoms last for
less than 5 minutes
5-60 minutes
more than 1 hour
17) About visual and sensory symptoms in question 15 and 16 (may choose more than one). If never have these symptoms, skip to question 18.
at least 2 attacks of visual symptom have ever occurred
visual symptom precedes within 1 hour before headache
visual symptom accompanies with headache
visual and sensory symptoms occur one after the other
visual or sensory symptom spreads gradually over at least 5 minutes
fully reversible, no remains of these symptoms
18) If headache attacks with each attack resolving completely, how often does the headache attack?
if it attacks every day, how many attacks a day?
if it attacks every week, how many attacks a week?
if it attacks every month, how many attacks a month?
if it attacks every year, how many attacks a year?
other details (if any)
19) Time of day that headache (usually) starts
waking up in the morning
sleep at night, causing wakening
uncertain
other
20) Over the past 3 months, symptoms have changed (may choose more than one)
more intense
more frequent
last longer
other changes either worsening or improvement
no changes
21) Triggers starting headache of
this type
(may choose more than one)
coughing
sneezing
straining
exerting
exercise
sexual activity
chewing
changing to upright posture (resolves after lying down)
stress
anxiety
depression
too much sleep
lack of sleep
during 2 days before menstruation
first 3 days of menstruation
certain odor
smoke
bright light
noise
intense use of eyes
hot weather
sunlight
cold weather
fasting
stopping coffee drinking
foods / drinks / drugs / other
no triggers of headache of this type
22) Any health problems (may choose more than one)
head injury within the past 3 months
pregnancy
after delivery within 2 months
tumor / cancer
weak immune system
blood pressure 180/120 or more
loud snoring / breathing pauses during sleep
other
no health problems
23) Any other
persisting symptoms even without headache
(may choose more than one)
nausea / vomiting
loss of smell
blurred vision
droopy eyelid (one side)
double vision
droopy mouth (one side)
hearing loss (one side)
ringing in ear(s)
limb weakness (one side)
unsteady movement
no
24) Any other symptoms (may choose more than one)
fever
convulsion
painful to touch at temple
other
no
25) Non-headache medication often used (may choose more than one)
contraceptives
hormone drugs
other (please specify the drug names)
no
26) Treatments used for headache
1) Drug name
2) Drug name
3) Drug name
4) Drug name
5) Effective nondrug measures (may choose more than one)
sleep
rest in a dark room
rest in a quiet room
other
6) Results of treatments (may choose more than one)
complete relief
partial relief
fewer attacks
no response
not sure
7) Other details about treatments, results, or side effects of drugs (if any)
8) If no drugs are used for headache, skip to question 28
27) If pain relievers for headache (drugs advised for occasional use when headache attacks) are used, how many days are they used in each month?
fewer than 10 days per month
10 days or more per month, less than 3 months
10-14 days per month, more than 3 months
15 days or more per month, more than 3 months
Caution
: regular use of pain relievers for headache on 10 days or more per month may be prone to medication-overuse headache.
28) Brain imaging test within 2 years
28.1) It was done with (may choose more than one)
CT scan
MRI
not done (skip to question 29)
28.2) The test results
normal
abnormal
29) Similar headache in family members (may choose more than one)
your father
your mother
your brother
your sister
your son/daughter
other
no
30) Impact on daily living by this type of headache
not at all
mild
moderate
severe
(The answers can be changed before seeing the report)
See Assessment Report
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