Post on 14-Jul-2020
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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):
Were you adopted: YES NO
Does anyone in the family have headaches (migraine, sick, sinus, tension, cluster, other):
Were you ever carsick as a child: YES NO
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
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
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
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)
©
PREVIOUS HEADACHE WORKUP -
PROCEDURES FOR HEADACHE -
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.
DATE RESPONSE
botox
nerve blocks
acupuncture
Innovative Medical Research 1997
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
Have you had any allergic reactions to any medications (if yes, please list below): YES NO
MEDICATION DOSE FREQUENCY
OVER-THE-COUNTER (including herbals & supplements) DOSE FREQUENCY
NAME OF MEDICATION PROBLEM
NEW PATIENT QUESTIONNAIRE - Page 6
PREVIOUS SURGERIES, ILLNESSES, & ACCIDENTS -
List and describe any surgeries that you have had:
List major illnesses that you have had:
List any serious accidents or injuries that you have had:
List any prior history of depression or psychological difficulty:
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
DATE OF SURGERY DESCRIPTION OF SURGERY
DATE OF ACCIDENT DESCRIPTION OF ACCIDENT
DATE EXPLAIN (hospitalization, outpatient treatment, etc)
DATE OF ILLNESS DESCRIPTION OF ILLNESS
NEW PATIENT QUESTIONNAIRE - Page 7
FAMILY HISTORY -
Do you know of any blood relatives who has or had any of the following:
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
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:
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 lymph node enlargement or tenderness (Location: )
frequent thirst / drinking / urination intolerance to heat or cold seasonal allergies (Explain):
Other:
NEW PATIENT QUESTIONNAIRE - Page 9
DAILY MEDICATIONS TAKEN IN THE PAST TO HELP PREVENT HEADACHE -
DRUG DOSE HOW LONG EFFECT ON HEADACHE
- NONSTEROIDAL ANTIINFLAMMATORIES -
ibuprofen (Motrin, Advil)
naproxen (Naprosyn)
celecoxib (Celebrex)
piroxicam (Feldene)
diclofenac (Voltaren)
indomethacin (Indocin)
meloxicam (Mobic)
nabumetone (Relafen)
other:
- CARDIAC MEDICATIONS -
timolol (Blocadren)
nadolol (Corgard)
propranolol (Inderal)
metoprolol (Lopressor,Toprol)
atenolol (Tenormin)
verapamil (Calan, Isoptin, Verelan)
amlodipine (Norvasc)
nifedipine (Procardia)
diltiazem (cardizem)
clonidine (Catapress)
other:
- PSYCHOTROPIC MEDICATIONS -
amitriptyline (Elavil)
nortriptyline (Pamelor)
imipramine (Tofranil)
doxepin (Sinequan)
desipramine (Norpramin)
protriptyline (Vivactil)
fluoxetine (Prozac)
sertraline (Zoloft)
paroxetine (Paxil)
citalopram (Celexa)
escitaloproam (Lexapro)
venlafaxine (Effexor)
desvenlafaxine (Pristiq)
duloxetine (Cymbalta)
mirtazapine (Remeron)
fluvoxamine (Luvox)
NEW PATIENT QUESTIONNAIRE - Page 10
DAILY MEDICATIONS TAKEN IN THE PAST TO HELP PREVENT HEADACHE (continued) -
DRUG DOSE HOW LONG EFFECT ON HEADACHE
trazodone (Desyrel)
nefazodone (Serzone)
bupropion (Wellbutrin)
phenalzine (Nardil)
tranylcypromine (Parnate)
aripiprazole (Abilify)
olanzapine (Zyprexa)
quetiapine (Seroquel)
risperidone (Risperdal)
ziprasodone (Geodon)
other:
- ANTISEIZURE MEDICATIONS -
valproic acid (Depakote)
gabapentin (Neurontin)
pregabalin (Lyrica)
phenytoin (Dilantin)
carbamazepine (Tegretol, Carbatrol)
oxcarbazepine (Trileptal)
topiramate (Topamax)
lamotrigine (Lamictal)
zonisamide (Zonegran)
tiagabine (Gabatril)
levetiracetam (Keppra)
other:
- MUSCLE RELAXANTS -
carisoprodal (Soma)
cyclobenzaprine (Flexeril)
methocarbamol (Robaxin)
tizanidine (Zanaflex)
baclofen (Lioresal)
orphenadrine (Norflex)
metaxalone (Skelaxin)
other:
- ANTIANXIETY AGENTS -
diazepam (Valium)
clonazepam (Klonopin)
alprazolam (Xanax)
lorazepam (Ativan)
NEW PATIENT QUESTIONNAIRE - Page 11
DAILY MEDICATIONS TAKEN IN THE PAST TO HELP PREVENT HEADACHE (continued) -
What medications have worked best for you:
What medications have worked best for a family member with headache:
MEDICATIONS USED TO TREAT HEADACHE ACUTELY (as needed) -
DRUG DOSE HOW LONG EFFECT ON HEADACHE
- PAIN MEDICATIONS -
hydrocodone / apap (Lortab, Vicodin)
acetaminophen with codiene (Tylenol #3)
extended release oxycodone (Oxycontin)
extended release morphine (MS Contin, Kadian, Oramorph)
fentanyl patch (Duragesic)
methadone
tramadol (Ultram)
tapentadol (Nucyncta)
oxymorphone (Opana)
- SLEEP MEDICATIONS -
zolpidem (Ambien)
zaleplon (Sonata)
eszopiclone (Lunesta)
ramelteon (Rozerem)
chloral hydrate (Somnote)
melatonin
other:
- OTHER -
methysergide (Sansert)
cyproheptadine (Periactin)
memantine (Namenda)
DRUG DOSE EFFECTIVE NOT EFFECTIVE NUMBER OF DAYS USED PER WEEK
isometheptene / dichloralphenazone/apap (Midrin)
ergotamine (Cafergot, Wigraine)
butalbital / apap / caffeine (Fioricet) with or without codiene
butalbital / asa / caffeine (Fiorinal) with or without codiene
apap / asa / caffeine (Excedrin)
NEW PATIENT QUESTIONNAIRE - Page 12
MEDICATIONS USED TO TREAT HEADACHE ACUTELY (continued) -
DRUG DOSE EFFECTIVE NOT EFFECTIVE COMMENTS
apap / codiene (Tylenol #3)
hydrocodone / apap (Lortab, Vicodin, Norco)
oxycodone (Percocet, Roxicet)
meperidine (Demerol)
morphine
hydromorphone (Dilaudid)
tramadol (Ultram)
ibuprofen (Motrin, Advil)
naproxen (Aleve, Naprosyn)
celecoxib (Celebrex)
ketorolac (Toradol) tablet
ketorolac (Toradol) injection
dihydroergotamine injection
dihydroergotamine nasal spray (Migranal)
dihydroergotamine inhaler (Levadex)
sumatriptan SQ injection (Imitrex, Sumavel)
sumatriptan nasal spray (Imitrex)
sumatriptan tablets (Imitrex)
zolmitriptan nasal spray (Zomig)
zolmitriptan (Zomig) ZMT or tab
rizatriptan (Maxalt) MLT or tab
almotriptan (Axert)
frovatriptan (Frova)
naratriptan (Amerge)
eletriptan (Relpax)
sumatriptan + naproxen (Treximet)
lidocaine nose drops
oxygen
butorphanol nasal spray (Stadol)
butorphanol injection (Stadol)
steroids (Prednisone, Medrol Dose Pack)
other:
NEW PATIENT QUESTIONNAIRE - Page 13
MEDICATIONS USED TO TREAT NAUSEA AND/OR VOMITING -
What medications have worked best for you:
SUPPLEMENTS OR HERBAL PRUDCES USED FOR HEADACHE -
DRUG DOSE EFFECTIVE NOT EFFECTIVE COMMENTS
promethazine injection (Phenergan)
promethazine tablets (Phenergan)
promethazine suppositories (Phenergan)
prochlorperazine injection (Compazine)
prochlorperazine tablets (Compazine)
prochlorperazine suppositories (Compazine)
trimethobenzamide capsules (Tigan)
trimethobenzamide suppositories (Tigan)
metoclopramide (Reglan)
hydroxyzine (Vistaril)
ondansetron tablets (Zofran)
ondansetron injection (Zofran)
other:
PRODUCT DOSE EFFECTIVE NOT EFFECTIVE COMMENTS
butterbur (Petadolex)
feverfew
riboflavin (Vitamin B2)
magnesium
coenzyme Q10
fish oil
5-hydroxytriptophan (5-HTP)
St. John’s Wort
ginger
migrelief
other:
NEW PATIENT QUESTIONNAIRE - Page 14
PHQ-9 TEST (Use a check mark to indicate your answer) -
Over the last 2 weeks, how often have you been bothered by the following problems?
NOT AT ALL SEVERAL DAYS MORE THAN HALF THE DAYS NEARLY EVERY DAY
Little interest or pleasure in doing things. 0 1 2 3
Feeling down, depressed, or hopeless. 0 1 2 3
Trouble falling or staying asleep, or sleeping too much.
0 1 2 3
Feeling tired or having little energy. 0 1 2 3
Poor appetite or overeating. 0 1 2 3
Feeling bad about yourself–or that you are a failure or have let yourself or your family down.
0 1 2 3
Trouble concentrating on things, such as reading the newspaper or watching television.
0 1 2 3
Moving or speaking so slowly that other people could have noticed? Or the opposite–being so fidgety or restless that you have been moving around a lot more than usual.
0 1 2 3
Thoughts that you would be better off dead or of hurting yourself in some way.
0 1 2 3
(FOR OFFICE CODING: 0 + + + = Total Score )
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get
along with other people: not difficult at all somewhat difficult very difficult extremely difficult
GAD-7 TEST (use a check mark to indicate your answer) -
Over the last 2 weeks, how often have you been bothered by the following problems?
NOT AT ALL SEVERAL DAYS MORE THAN HALF THE DAYS NEARLY EVERY DAY
Feeling nervous, anxious or on edge. 0 1 2 3
Not being able to stop or control worrying. 0 1 2 3
Worrying too much about different things. 0 1 2 3
Trouble relaxing. 0 1 2 3
Being so restless that it is hard to sit still. 0 1 2 3
Becoming easily annoyed or irritable. 0 1 2 3
Feeling afraid as if something awful might happen.
0 1 2 3
(FOR OFFICE CODING: Total Score T = + + )
*The PHQ-9 & GAD-7 tests were developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc.
END OF QUESTIONNAIRE - Thank you for your patience.