Patient's name

URN

 

HEADACHE ASSESSMENT FORM

HISTORY
Headache
(Circle as many as you need)
Onset Sudden Rapid Gradual Chronic _______ hrs/days
(secs) (min) (hrs/days)
Character Throbbing Constant
Location Unilateral Bilateral Frontal Vertex
Temporal Occipital
Parietal
Chronology Unremitting Intermittent
Worsening Improving Unchanging Fluctuating
Worse in morning
Alleviating factors Analgesia/Dose/Frequency__________ Other ______________________
(Give details) (Give details)
Aggravating factors Coughing Sneezing Head forward Head forward
Straining Bending Lying down
Similar to usual migraine? N/A Yes No (specify below)
____________________________________________
Associated symptoms Fever Vomiting  Photophobia
History of trauma No When?___________  (hrs/days/wks)
Sinus  symptoms Post nasal drip Nasal congestion Maxillary toothache 

Dental symptoms

Toothache Gum swelling
Ear symptoms Deafness Ear Discharge
Jaw symptoms Locking Clicking Claudication
Eye symptoms Eye pain Visual disturbance
Additional comments: ___________________________________________________________________________
Past surgery Dental  ENT Eye
Past medical history Polymyalgia rheumatica Sinusitis Glaucoma Migraine
Previous migraine treatment (specify)
Past medical history

Medications

Anticoagulants
(specify)__________________________________________

EXAMINATION

Vital Signs

Temp_____ PR _____ BP ______ SaO2 _____% RR_______

GCS

E ______ V_______ M_____
Meningism Fever Dehydration Tachycardia
Neurological exam
Cranial Nerves Gaze palsy Facial droop Other   _____________________
Power Unilateral  weakness Other ________________________
Co-ordination Ataxia Limb incoordination
Sensation Unilateral paraesthesia  Sensory inattention

Head

Temporal artery tenderness Scalp injury Facial tenderness

ENT

Red drum Haemotympanum CSF Otorrhea Nasal congestion

Eyes

Red eye Corneal haze Non-reactive pupil Globe tenderness

Sinus

Percussion tenderness
Fundi Papilloedema Optic neuritis
Pupils Unequal
DIFFERENTIAL DIAGNOSES MANAGEMENT PLAN