Migraine Clinic Proforma
Date: ___/___/___
Full Name: ______
Date of Birth: ___/___/___
Address: ______
______
Sex: Male ♂ Female ♀
Please try to answer all the questions if possible.
History and Symptoms:
Occupation:
Do you work under fluorescent lighting? Yes r No r
If yes, how much time do you typically spend under fluorescent lights?
r more than 4 hours a day
r 1 to 4 hours a day
r 1 to 7 hours a week
r less than a one hour a week
Do you use computer screens? Yes r No r
If yes, how much time do you typically use a computer?
r many hours a day
r a few hours a day
r a few hours a week
r less than a few hours a week
Ophthalmic History
Date of last eye examination:
Were you given glasses Yes r No r
If so, when are they worn? rJust Distance Vision
rJust Near Vision
rAll the Time
Has anyone ever noticed your eye(s) turning inwards or outwards?
Yes r No r
If yes, at what age, how often, and how long did it normally last?
Have you ever had an eye operation?
Yes r No r
Please give any details you can of what the operation was for and how you were at the time
Have you ever received eye exercises, or eye patching for a lazy eye?
Yes r No r
Please give details of the type of treatment and how old you were at the time
Have you ever had an injury to your eyes?
Yes r No r
Please give details of the injury and how you were at the time
Developmental History
Please state whether your mother's pregnancy was full term, or how many months/weeks early or late you were born:
Please state whether the birth was normal, or give details of any complications
(for example, was it a forceps delivery?):
Please list any severe illnesses / operations that you had in your first year, with approximate age at the time:
Visual Symptoms
When you look at writing in the distance (e.g. on a traffic sign), is it normally clear?
Yes r No r
Do things in the distance ever go blurred?
Yes r No r
When you are reading or writing in a book, is it normally clear?
Yes r No r
Do words in a book ever: go blurred? Yes r No r
jump around? Yes r No r
go smaller/ bigger? Yes r No r fade or disappear? Yes r No r
get faint colours round them? Yes r No r
other
Have you ever experienced double vision? Yes r No r
Do you ever experience sore or tired eyes? Yes r No r
Visual Behaviour
Have you or anyone else ever noted that you ;
Yes No If so, please give details
Hold reading or materials unusually
close or far away: r r
Close or cover one eye: r r
Rub your eyes frequently: r r
Blink your eyes excessively: r r
Tilt your head when reading or writing: r r
Move your head when reading: r r
Use your finger as a marker: r r
Confuse letters or words: r r
Reverse letters or words: r r
Skip, re-read or omit words or lines: r r
Read slowly: r r
Tire easily: r r
Have poor general coordination: r r
Are light sensitive: r r
General Health
Are you in good physical condition and healthy? Yes r No r
If no, please give details:
Please list any pills or medicines that you are currently using excluding any for migraine or headaches, which are detailed below:
Have you ever received hospital treatment as an in-patient? Yesr Nor
If yes, please give brief details
Have you ever suffered from epilepsy, or any fits or convulsions? Yesr Nor
If yes, please give brief details, including age at time
Please give details of any allergies, including hay fever and asthma, that you have ever suffered from. Please say how old you were, how long the problem lasted and how severe it was:
Headaches
Have you ever been diagnosed as suffering with migraine headache?
Yes r No r
If yes, was the diagnosis made by GP r Neurologist r Other r
Think of the worst headache you have had in the last 12 months. How bad was it? -
r Mild
r Moderate
r Severe
How Long Did The Pain Last: _____Hrs
Description of Pain: r Aching
r Throbbing / Pulsating
r Sharp / Lancing
r Pressure / Squeeze
Associated Symptoms: r Sensitivity to Noise
r Feeling Sick
r Vomiting
r Ringing in the Ears
r Decreased Hearing
r Speech Difficulties
r Stammering
r Dizziness
r Numbness
r Tingling
r Weakness
r Double Vision
r Difficulty with movement
r Decreased level of consciousness
r Blind patches or blindness in one eye lasting
less than one hour
Light Sensitivity:
When you have a headache, how much of a problem do you find pain or discomfort from lights to be in your every day life?
r None
r Slight Problem
r Moderate Problem
r Marked Problem
r Severe Problem
When you have a headache, do lights or light cause your eyes to water?
r Not at all
r Slightly
r Moderately
r Markedly
r A lot
When you DO NOT have a headache, how much of a problem do you find pain or discomfort from lights to be in your every day life?
r None
r Slight Problem
r Moderate Problem
r Marked Problem
r Severe Problem
When you DO NOT have a headache, do lights or light cause your eyes to water?
r Not at all
r Slightly
r Moderately
r Markedly
r A lot
Please think of the headaches you have had over the last month, and whether they have been getting more frequent or less frequent. Use this information to arrive at your best guess as to how many headaches you have had in the last 12 months, and write the number here______
Please name any medications that have been prescribed by your doctor for headaches
______
Are your headaches aggravated by walking stairs or similar routine physical activity?
Yes r No r
Did you have any medical problems or injuries at or about the time the headaches started?
Yes r No r
If yes, please list; ______
Migraine Aura
Do you get changes before the headache starts (for example zig zag lines in your vision, speech difficulties, weakness or numbness)?
Yes r No r
If yes, please answer the following ;
Do these changes go away when the headache stops?
Yes r No r
Do these changes develop over more than four minutes?
Yes r No r
Do these changes last more than 60 minutes?
Yes r No r
Does the headache start within an hour of the changes starting?
Yes r No r
Headache Triggers
Some people notice that certain activities can start their headache. For the following activities please could you note if the following commonly, occasionally or never cause headaches:
Hormonal factors (females) rCommonly Causes Headache
(time of the month) rOccasionally Causes Headache
rNever Causes Headache
Stress rCommonly Causes Headache
rOccasionally Causes Headache
rNever Causes Headache
Noise rCommonly Causes Headache
rOccasionally Causes Headache
rNever Causes Headache
Tiredness rCommonly Causes Headache
rOccasionally Causes Headache
rNever Causes Headache
rCommonly Causes Headache
Smells rOccasionally Causes Headache
rNever Causes Headache
rCommonly Causes Headache
Chocolate rOccasionally Causes Headache
rNever Causes Headache
rCommonly Causes Headache
Cheese rOccasionally Causes Headache
rNever Causes Headache
rCommonly Causes Headache
Other foodstuffs rOccasionally Causes Headache
rNever Causes Headache
rCommonly Causes Headache
Red Wine rOccasionally Causes Headache
rNever Causes Headache
rCommonly Causes Headache
Other Alcohol rOccasionally Causes Headache
rNever Causes Headache
rCommonly Causes Headache
Caffiene (Tea, Coffee etc) rOccasionally Causes Headache
rNever Causes Headache
Flickering Lights rCommonly Causes Headache
rOccasionally Causes Headache
rNever Causes Headache
Certain Patterns rCommonly Causes Headache
rOccasionally Causes Headache
rNever Causes Headache
Alternate Light and Shade rCommonly Causes Headache
rOccasionally Causes Headache
rNever Causes Headache
Other Visual Simuli rCommonly Causes Headache
rOccasionally Causes Headache
rNever Causes Headache
Please describe any of these “other” visual stimuli that may trigger headaches: ______
Location of Pain
When you gat a headache, please could you indicate the usual location of the pain.
(Please see pictures below):
r 1: Occipital
r 2: Parietal
r 3: Vertex
r 4: Temple
r 5: Frontal
r 6: Orbital
Which side of the head was the pain mostly concentrated:
r Only Left
r Mainly Left
r Both Sides
r Mainly Right
r Only Right
Family History
Did your parents or any of the other children in your family have reading problems?
Yes r No r If yes, state who (e.g. father)
Did your parents or any of the other children in your family ever have a turning eye, patching, or eye exercises? Yes r No r If yes, state who
Are your parents or any of the other children in your family colour-blind?
Yes r No r If yes, state who
Are there any other eye conditions that run in the family?
Yes r No r If yes, please list
Did any relatives ever have epilepsy? Yes r No r If yes, state who
Did your parents or any of the other children in your family ever have migraine headaches? Yes r No r If yes, state who
Are there any other general health problems that run in the family?
Yes r No r If yes, please list
General Optometric Examination:
Slit Lamp
Ophthalmoscopy
Pupils
Size (Horizontal Diameter): R: mm L: mm (note illumination)
Reactions: Direct
Consensual
No RAPD
Wolffsohn’s Tests
Tonometry
R: mmHg L: mmHg
Time: ____ Instrument: ______
Visual Fields Medmont
Humphrey Frequency Doubling Fields
Humphrey 24;2
Focimeter Result of own spectacles
R: ______/______x______Add: ______
L: ______/______x______Add: ______
Spectral photometric analysis of Tint
Refractive Correlates:
Visions: R: ______
L: ______
Objective Refraction (Spot retinoscopy):
R: ______/______x______
L: ______/______x______
Subjective Refraction:
R: ______/______x______+1.00:
L: ______/______x______+1.00:
Amplitude of Accommodation:
R: ______D
L: ______D
Binoc: ______D
Visual Acuity:
Distance: R: ______
L: ______
Near: R: ______
L: ______
Binocular Vision Correlates (With habitual correction if worn >50% of the time):
Cover – Uncover Test:
Distance Horizontal Size: ______∆
r XOP r SOP
Recovery: 1 2 3 4 5
Distance Vertical Size: ______∆
r R/L r L/R
Recovery: 1 2 3 4 5
Near Horizontal Size: ______∆
r XOP r SOP
Recovery: 1 2 3 4 5
Near Vertical Size: ______∆
r R/L r L/R
Recovery: 1 2 3 4 5
Alternating Cover Test:
Distance Horizontal Size: ______∆
r XOP r SOP
Recovery: 1 2 3 4 5
Distance Vertical Size: ______∆
r R/L r L/R
Recovery: 1 2 3 4 5
Near Horizontal Size: ______∆
r XOP r SOP
Recovery: 1 2 3 4 5
Near Vertical Size: ______∆
r R/L r L/R
Recovery: 1 2 3 4 5
Mallett Unit:
Right Distance Horizontal Aligning Prism: ______∆
r Base In r Base Out
Left Distance Horizontal Aligning Prism: ______∆
r Base In r Base Out
Right Distance Vertical Aligning Prism: ______∆
r Base Up r Base Down
Left Distance Vertical Aligning Prism: ______∆
r Base Up r Base Down
Right Near Horizontal Aligning Prism: ______∆
r Base In r Base Out
Left Near Horizontal Aligning Prism: ______∆
r Base In r Base Out
Right Near Vertical Aligning Prism: ______∆
r Base Up r Base Down
Left Near Vertical Aligning Prism: ______∆
r Base Up r Base Down
Foveal Suppression Test:
Binocular Right ______Left _____ letters
Monocular Right ______Left _____
Stationary or Moving (reverse if necessary)
Stereopsis: Randot Shapes ______
Randot Circles ______
Maddox Rod (6m) Horizontal Size: ______∆
r XOP r SOP
Vertical Size: ______∆
r R/L r L/R
Maddox Wing Horizontal Size: ______∆ variability ±_____∆
r XOP r SOP
Vertical Size: ______∆ variability ±_____∆
r R/L r L/R
Convergence: Facility ______cycles per minute
Persuit ______cm
Jump r Overconvergence
r Versional movement
r Slow or hesitant movement
r No Movement / movement of one eye only
Fusional Reserves: Distance base out vergence: ______∆ Blur
______∆ Break
______∆ Recovery
Distance base in vergence: ______∆ Blur
______∆ Break
______∆ Recovery
Near base out vergence: ______∆ Blur
______∆ Break
______∆ Recovery
Near base in vergence: ______∆ Blur
______∆ Break
______∆ Recovery
Motility:
Visual Function Correlates:
Colour Vision: D15
Frequency Doubling Perimetry:
Medmont flicker program:
Colorimetry Correlates:
Overlay assessment:
(Use standard protocol for overlay assessment as used in the SpLD Clinic and attach the results sheet)
Wilkins Rate of Reading Score (where reported benefit from overlay):
Use standard protocol and attach results sheet
Visual Stress Correlates:
Pattern glare tests:
Initial comments:
control experim.
Question / no / mild / sev. / no / mild / sev.do you see a colour or colours?
do the lines appear to bend?
do the lines seem to blur?
does the pattern flicker?
do the lines wobble or shimmer?
do parts of the pattern disappear and reappear?
any other illusions (please describe) ?