UPDOX - PATIENT PORTAL

Name: * Date of Birth: * Today's Date: * How did the headaches start and how often do they occur? * When did the headaches first start? * How long have the headaches been present? * Are the headache the same each time or are they different each time * How often do the headaches occur and are they becoming more frequent? * Do you know what causes the headaches (for example, certain situations, foods, or medications usually trigger the headaches) * Does physical activity aggravate the headache pain? * Are there any other symptoms that are associated with the headaches? ( for example, weakness, visual change, loss of consciousness) * Does anyone else in the family have headaches? * What symptoms, if any, occur between headaches? * Where is the pain located? * What does it feel like? * How severe is the headache pain using a scale from 1-10 10 being the worst pain you have felt * Do the headaches appear suddenly without warning or with accompanying symptoms? * What time of day do the headaches usually occur? * Is there an aura (changes in vision, blind spots, or bright lights) before the headaches? * What other symptoms occur with the headaches (weakness, nausea, sensitivity to light or noise, decreased appetite, change in attitude or behavior) * How long do the headaches last? * What relieves the headaches: Rest / Medicine? * Is there any other history in which you want to share? * Name and D.O.B. of Guardian completing form * Today's date * Electronic Signature of Guarantor/Guardian *