BIOGRAPHICAL DATA

Name: Race or ethnic background:

Address: Primary and secondary languages (spoken and read):

Phone: Marital Status:

Gender: Religious or Spiritual Practices:

Provider of History: Educational Level:

Birth Date: Occupation:

Place of Birth: Significant others or support persons (availability):

REASONS FOR SEEKING HEALTH CARE (CHIEF COMPLAINT)

HEADACHE
HISTORY OF PRESENT ILLNESS (COLDSPA)
Character: Describe how the headache feels (sharp, throbbing, Severity: How severe is the headache? Rate it on a scale of 1
dull)? to 10 (10 being most severe). Does the headache keep you
from doing your usual activities of daily living? Explain.

Onset: When did it first begin? Does it tend to occur with other Pattern: What aggravates it? What makes the pain go away?
factors? What pain relievers work best for you?

Locations: Where does your headache begin? (Ask client to point to Associated Factors: Do you have other symptoms with the
area in head if possible.) Does it radiate or spread to other areas? headache such as nausea, visual changes, dizziness, or
sensitivity to noise or light?

Duration: How long does it last? How often does it recur? Has there Do you have any facial pain? Describe.
been any change in the duration of your headaches? Explain.

PAST HEALTH HISTORY

Childhood illness: (immunizations) Hospitalizations and/or surgeries:

Adulthood illness: (physical, emotional, mental) Medications:

Accidents/Injuries: Allergies:

GYNECOLOGIC AND OBSTETRIC HISTORY

Menarche (When did your period start?): Last Sexual Activity:
Regularity of Menstrual Cycle: History of previous and present pregnancy:
Use of Contraceptives:
FAMILY HISTORY
Is there a history of migraine headaches or any types of headaches in Past family medical history:
your family? Arthritis:
Cancer:
Diabetes mellitus:
Is there a history of head or neck cancer in your family? Heart disease (heart failure, MI, valve disease):
Hypertension/ High blood:
Stroke
LIFESTYLE AND HEALTH PRACTICES
Diet and Exercise? Do you wear a helmet when riding a horse, bicycle,
motorcycle, or other open sports vehicle (e.g., four-wheeler,
go-cart)? Do you wear a hard hat for hazardous
occupations?

Do you smoke or chew tobacco? If yes, how much? What is your typical posture when relaxing, during sleep,
and when working?

Do you use alcohol or recreational drugs? Describe the type used and
how much.

In what kinds of recreational activity do you participate? Describe Have any problems with your head or neck interfered with
the activity your relationships with others or the role you occupy at
home or at work?