Migraines and Headache History Assessment
Patient Details
Full Name
Date of Birth
Date of Assessment
Headache History
When did the headaches start?
How often do you have headaches?
How long do the headaches last?
Where is the pain located?
Describe the pain (e.g., throbbing, sharp):
Severity (1-10):
Associated Symptoms
Do you experience any of the following? (select all that apply)
Nausea
Vomiting
Visual changes (Aura)
Sensitivity to light
Sensitivity to sound
Other
If other, please specify:
Triggers
Do any factors trigger your headaches?
Relieving Factors
What helps to relieve your headaches?
Current and Past Treatments
Medications tried (past and present):
Other treatments (e.g., physical therapy, lifestyle changes):
Family History
Is there a family history of migraines or headaches?
Comments / Additional Notes