Headache

Headache - {{first name}} {{surname}}

PERSONAL INFORMATION

First Name

Surname

Date of Birth

Email Address

Mobile Phone

Home Phone

Home Address

Medicare Card Number - (IRN) *

How did you find out about us?

PERSONAL HEALTH HISTORY

1. Characteristics of a headache:

Characteristics of a headache

Throbbing or pulsating painSharp or stabbing painDull or aching painPressure or band-like sensation around the headPain on one side of the headPain on both sides of the headPain at the back of the head or neck

Other

Onset and Duration:

Sudden onset of headacheGradual onset of headacheHeadache lasting less than 1 hourHeadache lasting several hoursHeadache lasting days or longerRecurring headaches over time

Other

Frequency of headaches

Occasional headaches (less than once a month)Frequent headaches (several times a month)Chronic or daily headaches

Other

Triggers

Stress or emotional tensionLack of sleep or changes in sleep patternsSkipped meals or hungerCertain foods or drinks (e.g., caffeine, alcohol, chocolate)Bright lights or loud noisesPhysical activity or exertionWeather changes or air pressure changesHormonal changes (e.g., menstrual cycle, pregnancy)

Other

Associated Symptoms (mark only one)

Nausea or vomitingSensitivity to light (photophobia)Sensitivity to sound (phonophobia)Visual disturbances (e.g., blurry vision, flashing lights)Dizziness or lightheadednessNeck pain or stiffnessFatigue or difficulty concentrating

Other

Medical History

History of migrainesHistory of tension headachesHistory of cluster headachesRecent head injury or traumaHigh blood pressureSinus infections or allergiesUsing medications - e.g oral contraceptive pill

List your medical conditions (Asthma, Diabetes etc.)

List of Medications (Include name, dose and frequency)

Please list any allergies.

Additional Notes

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DECLARATION

I confirm that the above information I have provided is true, complete and accurate. I agree to be contacted by a health professional via telehealth.

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