Medication & Non-Medication Historyform

MEDICATION & NON-MEDICATION HISTORYFORM

Pleasehighlightorcirclemedicationsyouhavetried. Please indicate iftheyworked(W), didn’t work (DW) or if there were any side effects (SE).

OvertheCounter

Acetaminophen(Tylenol) / Anacin / Aspirin FreeExcedrin / Ibuprofen(Motrin,Advil)
Aleve / Aspirin / ExcedrinMigraine

Herbal/Vitamin

Deplin / Gliacin / Migravent / VitaminB2(riboflavin)
Feverfew / MagnesiumOxide / Petadolex(butterbur) / Turmeric

PrescriptionPainMedications

Fioricet/ Esgic (Butalbital/Acetaminophen/Caffeine) / Methadone(Dolophine)
Fiorinal(Aspirin/Butalbital/Caffeine) / MorphineIV/IMMSContin,Avinza, Kadian
Fiorinal with Codeine/FioricetwithCodeine/Fiorinal#3 / Nucynta
Phrenilin (Butalbital/Acetaminophen) / OxyContin
NaproxenSodium(Anaprox,Naprelan,Naprosyn) / Percocet,Percodan,(Oxycodone)
SprixNasalSpray / StadolNasalSpray
Toradol(Ketorolac)Tabs,injections, IV / Tylenol#3or#4
Butrans Patch / Ultram(Tramadol) / Ultracet
Demerol(Meperidine) / Vicodin,Vicoprofen,Lorcet(Hydrocodone), Norco
Dilaudid / Zohydro
Fentora / Other ______

HeadacheMedications

Imitrex(Sumatriptan)tablets,NasalSprayInjections (Sumavel, Zembrace)

Maxalt(Rizatriptan)tabletorMLT(dissolves) Midrin(isomethep/dichloralphen/acet.)

Zomig(Zolmitriptan)orZMT(dissolves), NasalSpray Prodrin (isometheptene/caffeine/acet.)

Amerge(Naratriptan) / Onzentra Xsail (sumatriptan nasal) / Cambia
Axert(Almotriptan) / Relpax / MigranalNasalSpray
Frova / Treximet / DHEIV,IM

AntiInflammatory

Arthrotec / Indocin(Indomethacin) / Voltaren(Diclofenacsodium)
Celebrex(Celecoxib) / Mobic (Meloxicam) / Other ______

BloodPressure

Atenolol(Tenormin) / Metoprolol (Lopressor,Toprol XL) / Atacand(Candesartan)
Bystolic / Nadolol(Corgard) / Benicar
Inderal(Propranolol) / Verapamil(Calan) / Losartan (Cozaar)
Other ______

Anti-DepressantMedications

Desipramine (Norpramin) / Paxil(Paroxetine) / Effexor(Venlafaxine)
Doxepin / Prozac(Fluoxetine) / Fetzima
Elavil(Amitriptyline) / Viibryd / Pristiq (Desvenlafaxine)
Pamelor(Nortriptyline) / Zoloft(Sertaline) / Remeron(Mirtazapine)
Vivactil(Protriptyline) / Brintellix or Trintellix / Trazodone(Desyrel)
Celexa (Citalopram) / Cymbalta (Duloxetine) / Wellbutrin(Bupropion)
Lexapro (Escitalopram) / Deplin / MAO inhibitors (Emsam, Nardil)
Other______

Anti-SeizureMedications

Depakote (divalproex sodium) / Keppra / Trileptal(Oxcarbamezaapine)
Gabapentin,Gralise(Neurontin) / Oxtellar XR / Zonegran (Zonisamide)
Gabitril / Topamax(Topiramate) Trokendi XR, Qudexy / Other ______

MoodStabilizer

Lamictal(Lamotrigine) / Rexulti / Seroquel(Quetiapine),XR
Lithium(Eskalith,Lithobid) / Saphris / Zyprexa
Other ______

MuscleRelaxerMedications

Baclofen / Norflex / Skelaxin(Metaxalone)
Flexeril(Cyclobenzaprine), Amrix / ParafonForte(Chlorzoxazone) / Soma(Carisoprodol)
Robaxin / Zanaflex(Tizanidine)

AntiNauseaMedications

Compazine(Prochloperazine) / Reglan(Metoclopramide) / Zofran(Ondansetron)
Phenergan(Promethazide) / Tigan(Trimethobenzamide) / Ginger

Anxiety

Ativan(Lorazepam) / Diazepam(Valium) / Xanax(Alprazolam)
Buspar(Buspirone) / Klonopin(Clonazepam) / Other ______

Corticosteroids

Decadron / Medrol / Prednisone

OtherMedicationsor Treatment:

BotulinumToxin(Botox) / TriggerPointInjection / SPG Block

ADD/ADHD

Adderall / Concerta / Focalin / Intuniv / Vyvanse
AdderallXR / Dexedrine / Focalin XR / Ritalin
Fibromyaligia / SleepMedications
Lyrica / Savella / Ambien / Belsomra / Lunesta / Rozerem / Silenor
OTC’s / Other _____

Miscellaneous

Low-Dose Naltrexone (LDN) / Namenda

Outside of Medication - Please IndicateIf It Helped(Y) or (N)

Physical Therapy / Biofeedback
Psychotherapy / Massage
Meditation / Miscellaneous
Acupuncture

EmergencyRoom

Whatmedicationsworkedintheemergencyroom?

Whatmedicationsdidn’tworkintheemergencyroom?

Robbins Headache Clinic 2610 Lake Cook Rd., Suite 160, Riverwoods, IL 60015 847-374-9399 8/10/16

Headache Intake Assessment Form

Name: ______Date: ______

Age: ______Sex: M F Marital Status: ______

Name of Spouse: ______

Name(s) and Age(s) of Children: ______

______

Names and Types of Pets: ______

Education: ______

Occupation: ______Spouse’s Occupation: ______

Does anyone in your family have headaches, or have they had moderate-to-severe headaches in the past?

If yes, please specify. ______

How old were you when you started having headaches? ______

How often do you have a mild-moderate headache? ______

How often do you have a severe headache/migraine? ______

How long do the severe headaches last? ____ hours ____ one day ____ two days ____ three or more days

On a scale of one to ten, with ten being the worst, how severe are the headaches?

1 2 3 4 5 6 7 8 9 10

Mild ModerateSevere

Do you have some type of headache every day? ______

How much do these daily headaches bother you? Mildly ______Moderately ______Severely ______

Where does the pain occur for your daily headaches? ______

Where does the pain occur for your severe headaches/migraines? ______

What does your headache typically feel like? (please circle one)

Throbbing/pulsing Pressing/squeezing Sharp/stabbing Dull/achy

Does your eye tear on the side of the headache?YesNo

Are the headaches much worse in the last few months?YesNo

Are the headaches much worse in the last year?YesNo

Do you frequently have nausea with your headaches?YesNo

Do you typically have visual problems with your headaches YesNo

such as flashing lights, sprinkles of light or vision loss on one side?

Do you typically experience sensitivity to light?YesNo

Do you typically experience sensitivity to sound?YesNo

Are your headaches worse before or during you menstrual cycle?YesNo

Do you take any birth control pill or hormone?YesNo

Circle the following if these play a role in your

Headaches or in producing an occasional headache:

stressexercise

after stress is overexertion

weather changesmissing a meal

foodscigarette odor

bright sunlightperfume odors

sexual activitydifferent seasons:

undersleepingsummer

oversleepingfall

hormonal changeswinter

menstrual cyclespring

Do you have very cold feet and hands in winter? YesNo

Have you had any of the following tests?

CT scan for your headaches? Y or NIf so, when? ______Results ______

MRI for the headaches? Y or NIf so, when? ______Results ______

Blood tests in the past year? ______Were they normal? ______

Have you tried Biofeedback or relaxation training for headaches? Yes No

If yes, has it helped? ______

______

How much do you exercise and what do you do? ______

______

Which doctors have you seen for headaches, if any? ______

______

______

Which family doctors or other doctors do you see? ______

______

______

______

______

Do you smoke cigarettes?YesNo If yes, how many? ______

Do you drink alcohol?NeverOccasionallyDaily

Have you had any type of problem with addictive drugs in the past? ______

Do you tend to be anxious or nervous? YesNo

If yes, is your anxiety mild, moderate or severe? ______

Do you have a history of depression?YesNo

If yes, when was your last episode? ______Is/was it:Mild Moderate or Severe

Do you have trouble sleeping?YesNo

If yes, do you have trouble going to sleep or staying asleep? ______

Other past medical history:

Operations? ______

______

Ulcers or stomach problems? ______

______

Asthma? ______

______

Any other medical problems? ______

______

______

______

Side effects or allergies to any medications? ______

______

______

What medications are you currently taking? ______

______

______

______

Robbins Headache Clinic847-374-9399

2610 Lake Cook Road, Suite 160, Riverwoods, IL 60015

STRESS FORM

Robbins Headache Clinic

Name: ______Date:______

How did you hear abut the practice? ______

If referred, name and phone number of referring physician: ______

Do you have any siblings? Names and ages (if applicable)

Describe briefly (personality traits, medical problems, etc.):

Father: ______

Mother: ______

List several traits that best describe your personality: ______

History of clinical/counseling intervention: Yes No

If yes, was it Inpatient or Outpatient (circle one) Dates: ______Currently ongoing: Yes No

Primary therapist was/is: (circle one) Psychiatrist Marriage Counselor Psychologist Social Worker

Other (Please describe) ______

Primary reason for seeing the above: ______

(Turn page over)

The current areas in which I am under stress include the following: (circle all that apply)

WorkMarriage

SchoolFinancial Pressure

Time ManagementRelationship/Interactions w/ parents

Relationship/Interactions w/ childrennone of the above

Other (please list below)

Please elaborate briefly on any items checked above: ______

______

Please note if any of the following apply to you: you may elaborate briefly on any that apply

History of alcoholism in family ______

Emotional abuse as a child ______

Early or recent head injury ______

Suicidal thoughts (past or present) ______

Friends and family members do not understand or appreciate the nature of your headaches:

Over the last 2 weeks how often have you been bothered by any of the following problems?

More Nearly

Severalthan halfevery

(Use “✓” to indicate your answer)Not at all daysthe days day

1. Little interest or pleasure in doing things 01 2 3

2. Feeling down, depressed, or hopeless 01 2 3

3. Trouble falling or staying asleep, or sleeping too much 01 2 3

4. Feeling tired or having little energy 01 2 3

5. Poor appetite or overeating 01 2 3

6. Feeling bad about yourself – or that you are a 01 2 3

failure or have let yourself or your family down

7. Trouble concentration on things, such as reading 01 2 3

the newspaper or watching television

8. Moving or speaking so slowly that other people could 01 2 3

have noticed? Or the opposite – being so fidgety or

restless that you have been moving around a lot more

than usual

9. Thoughts that you would be better off dead or of 01 2 3

hurting yourself in some way

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 SomewhatVeryExtremely

at all difficult difficult difficult

☐☐☐ ☐

Developed by Drs.Robert L Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer, Inc. No permission required to reproduce, translate, display or distribute.