NEW PATIENT QUESTIONNAIRE - Page 1

__________________________ Clinical Neurosciences Center NEW PATIENT QUESTIONNAIRE - Page 1 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): 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 Were you adopted: YES NO Does anyone in the family have headaches (migraine, sick, sinus, tension, cluster, other): 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 Were you ever carsick as a child: YES NO NEW PATIENT QUESTIONNAIRE - Page 2 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: NEW PATIENT QUESTIONNAIRE - Page 3 OTHER SYMPTOMS ASSOCIATED WITH YOUR HEADACHES - Aura Symptoms It is common to experience visual symptoms , vertigo, slurred speech and trouble thinking with migraine. These are not aura. Aura is typically a visual disturbance that starts and gradually progresses usually prior to headache.Symptoms include flashing lights, zig-zag lines, spots or holes in the vision. Aura can also be sensory with numbness and tingling that moves over the face, limbs and tongue. Aura can also affect your speech leading to word finding difficulty. In aura these symptoms must be progressive and last a minimum of 5 minutes and may last up to 1 hour. Symptoms typically resolve once headache begins. 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 - NEW PATIENT QUESTIONNAIRE - Page 4 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) © Innovative Medical Research 1997 PREVIOUS HEADACHE WORKUP - 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. PROCEDURES FOR HEADACHE - DATE RESPONSE botox nerve blocks acupuncture NEW PATIENT QUESTIONNAIRE - Page 5 CURRENT MEDICATIONS AND ALLERGIES - Are you taking any prescriptions and/or non prescriptive medications (if yes, please list below): YES NO MEDICATION DOSE FREQUENCY OVER-THE-COUNTER DOSE FREQUENCY (including herbals & supplements) Have you had any allergic reactions to any medications (if yes, please list below): YES NO NAME OF MEDICATION PROBLEM NEW PATIENT QUESTIONNAIRE - Page 6 PREVIOUS SURGERIES, ILLNESSES, & ACCIDENTS - List and describe any surgeries that you have had: DATE OF SURGERY DESCRIPTION OF SURGERY List major illnesses that you have had: DATE OF ILLNESS DESCRIPTION OF ILLNESS List any serious accidents or injuries that you have had: DATE OF ACCIDENT DESCRIPTION OF ACCIDENT List any prior history of depression or psychological difficulty: DATE EXPLAIN (hospitalization, outpatient treatment, etc) 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 NEW PATIENT QUESTIONNAIRE - Page 7 FAMILY HISTORY - Do you know of any blood relatives who has or had any of the following: 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: 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 NEW PATIENT QUESTIONNAIRE - Page 8 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

Load more