HEADACHES

Name *

First Name

Last Name

Phone *

(###)

###

####

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

YES (before only)

YES (during only)

YES (both)

NO

Is your headache pain typically localized to one side? *

YES

NO

Do you have allergies or sinus issues that flare up? *

YES

NO

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

YES

NO

Do your headaches ever occur around your menstrual cycle? *

YES

NO

N/A

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

YES

NO

Do you typically notice any of the following triggers? (Check all that apply)

Bright lights or loud sounds

Strong smells or perfumes

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

Stress or emotional triggers

Sleep disturbances or irregular sleep patterns

Intense physical activity or exertion

Other

No triggers

Are you experiencing any of the following lately? (Check all that apply)

Visual disturbances (flashing, blind spots)

Numbness or tingling in limbs or face

Fluid retention or swelling

Mood changes or irritability

Breathing difficulties or TMJ discomfort

Do you notice any patterns between your headache days and: (Check all that apply) *

Sleep quality?

Dietary changes?

Stress levels?

Have you previously tried any interventions such as: (Check all that apply) *

Medications (anti-histamines, anti-inflammatory, etc.)

Breathing exercises or relaxation techniques

Cranial or cervical mobilizations

Other