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Headaches

Headache assessment form

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Question 1 of 17

How often do you experience headaches?

A

Daily

B

Several Times Per Week

C

Weekly

D

Monthly

E

Occasionally

Question 2 of 17

When did you first notice your current pattern of headaches begin?

A

Less than 4 weeks ago

B

1–3 months ago

C

4 months to 1 year ago

D

More than 1 year ago

Question 3 of 17

How do your headaches impact your ability to work, exercise, or perform daily activities?

Question 4 of 17

On a scale from 0 to 10, how much do your headaches interfere with your ability to work, exercise, or perform daily activities?

 

(0 = No interference at all, 10 = Completely prevents me from functioning)

Question 5 of 17

Do you experience sensory disturbances (e.g., visual changes, speech difficulties, numbness) before or during your headaches?

A

YES (before only)

B

YES (during only)

C

YES (both)

D

No

Question 6 of 17

Is your headache pain typically localized to one side?  If yes, is it left or right?

Question 7 of 17

Do you have allergies or sinus issues that flare up?

A

Yes

B

No

Question 8 of 17

Do you ever experience dizziness, vertigo, or nausea with your headaches?

A

Yes

B

No

Question 9 of 17

Do your headaches ever occur around your menstrual cycle?

A

Yes

B

No

C

N/A

Question 10 of 17

Do you have a history of traumatic brain injury (TBI) or repeated minor head impacts?

A

Yes

B

No

Question 11 of 17

Have you had recent dental work, jaw alignment issues, or TMJ symptoms?

A

Yes, I have been diagnosed with TMJ/TMD (Jaw Disorder)

B

Yes, I frequently clench or grind my teeth (Bruxism)

C

Yes, I have had extensive recent dental work

D

I frequently have jaw/face pain, clicking, or difficulty chewing

E

No, I do not believe my dental history is related

Question 12 of 17

Do you typically notice any of the following triggers?

(Select all that apply)
A

Bright lights or loud sounds

B

Strong smells or perfumes

C

Certain foods or drinks (e.g., alcohol, caffeine)

D

Stress or emotional triggers

E

Sleep disturbances or irregular sleep patterns

F

Intense physical activity or exertion

G

Neck tension

H

Jaw clenching

I

Upper back discomfort

J

Other

K

No triggers

Question 13 of 17

Are you experiencing any of the following lately?

(Select all that apply)
A

Visual disturbances (flashing, blind spots)

B

Numbness or tingling in limbs or face

C

Fluid retention or swelling

D

Mood changes or irritability

E

Breathing difficulties or TMJ discomfort

F

None of the above

Question 14 of 17

Do you notice any patterns between your headache days and:

(Select all that apply)
A

Sleep quality

B

Dietary changes

C

Stress levels

D

Other

E

None

Question 15 of 17

Have you previously tried any interventions such as:

(Select all that apply)
A

Prescription Medications

B

Breathing exercises or relaxation techniques

C

Cranial or cervical mobilizations

D

Anti-histamines, anti-inflammatories, etc.

E

Other

F

None

Question 16 of 17

For any questions answered "Other" please explain here, thank you.

Question 17 of 17

Based on your responses, we recommend discussing any concerns with your physician before beginning or continuing exercise or movement-based programs. This screening is not a diagnostic tool, but it can help guide safe and appropriate care in collaboration with your healthcare provider.

 

PLEASE TYPE YOUR NAME TO ACKNOWLEDGE

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