The code block below illustrates how one might use # and // as comments in your logic and calculations.

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if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
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	// Return '0' if the condition is False.
	0
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New Patient Headache Questionnaire

Returning?

A A A

Please complete the survey below for the UW Headache Clinic. This survey will allow us to be well informed of your current headache symptoms and provide opportunity for us to spend more time in the first visit addressing your specific preferences and goals.

Thank you!

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Time stamp

D-M-Y H:M

Diagnosis

Chronic migraine

Episodic migraine

Migraine with aura

Migraine aura without headache, added 10/9/17

Probable migraine- added 10/9/17

Episodic Tension type headache

Chronic Tension Type Headache

Cluster

Paroxysmal hemicrania

Hemicrania continua

SUNCT/SUNA

Other TAC

Hypnic headache

Primary Stabbing Headache

Cervicogenic

Post Traumatic

Secondary Headache

MOH

MOH triptan 3/2019 NM

MOH ibuprofen 3/2019 NM

MOH acetaminophen

MOH naproxen/aleve

MOH Excedrin

MOH opioid

MOH multiple

Chronic daily headache

Vertigo

Migraine with vertigo, added 10/9/17

Chronic vertigo added 5/1/18

Occipital neuralgia

Trigeminal neuralgia

Atypical facial pain, added 10/9/17

New daily persistent headache, added 11/2/17

Exertional headache, added 3/9/18

Primary Cough Headache

Primary Thunderclap Headache

Cold stimulus headache

External Pressure Headache

Sex headache

Nummular Headache (Coin shaped headache)

"SINUS" HEADACHE, added 5/7/18

RED FLAG - 2/27/19

Brain tumor 3/20/2019 NM

Post-concussive Syndrome, added 1/7/2020

Other

Not seen in Headache Clinic
YES- Means that patient filled out the survey but was not seen face-to-face yet
NO- seen in the headache clinic face-to-face

Yes

No

Outside chart available and reviewed

Yes

No

Chart Checked

Yes

No

Other:

New diagnosis

Yes

No

Diagnosis Missed

Chronic migraine

Episodic migraine

Migraine with aura

Migraine aura without headache, added 10/9/17

Probable migraine- added 10/9/17

Cluster

Hemicrania continua

Paroxysmal hemicrania

Other TAC

Episodic Tension type headache

Cervicogenic

Post Traumatic

Secondary Headache

MOH

New diagnosis MOH

Chronic Tension Type Headache

Chronic daily headache

Vertigo

Migraine with vertigo, added 10/9/17

Primary Stabbing Headache

Occipital neuralgia

Trigeminal neuralgia

Atypical facial pain, added 10/9/17

New Daily Persistent Headache added 3/13/18

Exertional headache, added 3/9/18

Hemiplegic Migraine, added 4/4/18

Other

Other:

MOH
Had MOH taking acute medication more than 10 or 15 days per month total depending on type?
( for just Tylenol or ibuprofen more than 15 days per month, triptans >10 days per month, or any combination 10 days per month)

Yes

No

Unsure

Have they had adequate prophylactic medication trial?

Yes

No

Refractory headache (to medications)-- failed adequate trials of preventive medicines, alone or in combination, from at least 2 of 4 drug classes
AHS 2008 RHSIS criteria
2 of 4 drug classes
1. Beta blockers
2. Anticonvulsants
3. Tricyclics
4. Calcium channel blockers

Yes

No

Refractory headache medications classes

AHS 2008 RHSIS criteria
2 of 4 drug classes
1. Beta blockers
2. Anticonvulsants
3. Tricyclics
4. Calcium channel blockers

Failed zero

Failed one class such as anti-epileptics, B-blockers

Failed 2 classes

failed 3 classes

failed 4 classes

failed 5 classes or more

Refractory number of medications tried ( includes propranolol, metoprolol, atenolol, valproate, topiramate, amitriptyline, candesartan, botox)
Does not include SSRIs, and SNRIs

Failed zero

Failed one medication

Failed 2 medications

failed 3 medications or more

Refractory by European Headache Federation (EHF) Failed 3 drugs , 3 months each or side effects

Beta blockers- propranolol, metoprolol, atenolol
Anticonvulsants - valproate, topiramate
Tricyclics - Amitriptyline
Other - flunarazine, candesartan,
BOTOX by PREEMPTprotocol

Yes

No

Refractory med class

Level A Beta-blockers (propranolol, timolol, metoprolol)

Level A Anti-seizure (Depakote, Topamax)

Level B TCAs (Amitriptyline)

Level B Beta-blockers ( Atenolol, Nadolol)

Level C - candesartan, carbamazepine, pindolol, cyproheptadine

Level U: fluoxetine, gabapentin, protriptyline, verapamil

SNRI ( duloxetine, Effexor -venlafaxine)

SSRI (sertraline, fluoxetine, celexa)

none

Other

Refractory medication

European Headache Federation (EHF)
3 drugs from
Beta blockers- propranolol, metoprolol, atenolol
Anticonvulsants - valproate, topiramate
Tricyclics - Amitriptyline
Other - flunarazine, candesartan,
BOTOX by PREEMPTprotocol

AHS 2008 RHSIS criteria
2 of 4 drug classes
1. Beta blockers
2. Anticonvulsants
3. Tricyclics
4. Calcium channel blockers

None

Depakote (divalproex) (A) (EHF)

Topiramate (topamax) (A) (EHF)

Metoprolol (A) (EHF)

Propranolol (Inderal) (A) (EHF)

Timolol (A)

Amitriptyline (B) (EHF)

Nortriptyline

Atenolol (B) (EHF)

Nadolol (B)

Candesartan (C)

Nebivolol (C)

Pindolol (C)

Duloxetine (Cymbalta)

Gabapentin (Neurontin) (U)

Verapamil (U)

Venlafaxine (Effexor)

Setraline (Zoloft) -does not count for trial

Citalopram (Celexa) -does not count for trial

Fluoxetine (Prozac) -does not count for trial

Zonisamide (Zonegram) - does not count for trial

Candesartan (EHF)

BOTOX (OnabotulinumA) (EHF)

Lamictal (lamotrigine)

other

Prophylactic medication trial

Preventive medication:

Insurance

English speaking patient?

Yes

No

Did the patient sign consent?

Yes

No

BMI

Is the patient's BMI more than 35?

View equation

Is the patient's BMI more than 30?

View equation

Is the patient's BMI more than 25?

View equation

Is the patient's BMI <25

View equation

Is the patient's BMI < 18.5

View equation

Is the patient's BMI 18.5=< x<25

View equation

Is the patient's BMI 25=< x< 30

View equation

Is the patient's BMI 30=< x< 35

View equation

Is the patient's BMI 35=< x

View equation

Provider edited responses during visit?

Yes

No

CEFALY prescription by UW headache clinic

Yes

No

CEFALY ordered

Yes

No

CEFALY returned

Yes

No

gammaCore prescription by UW

Yes

No

gammaCore ordered

Yes

No

gammaCore returned

Yes

No

Aimovig

Yes

No

Aimovig 70 mg UW prescribed

Yes

No

Aimovig 140 mg UW prescribed

Yes

No

Emgality UW prescribed

Yes

No

Ajovy UW prescribed

Yes

No

Positive response to anti CGRP

Yes

No

This headache questionnaire is crucial to help schedule your appointment and help us understand you and give you the best care.

By completing it, you maximize your time with us at the University of Washington Headache Clinic. This lets us focus on providing an accurate diagnosis and developing the best treatment plan for you.

Please fill out this form to the best of your knowledge: if you aren't completely sure about an answer, give the answer you think is most correct. Some parts of the questionnaire are repetitive, it is sometimes necessary to ask the same question in different ways.

Feel free to fill this out with the help of your family and other healthcare providers. We can schedule your appointment only once this form is completed. If you are unable to fill out this form please notify us as soon as possible.

1A. What is your last name?

* must provide value

1B. What is your first name?

* must provide value

1C. What is your date of birth?

* must provide value

M-D-Y

Are you currently taking opioids for headache or any other type of pain?

Yes

No

If you use opioids , headache specific treatments are not very effective. Please see your primary care provider for next steps. Our clinic is happy to see you after you successfully stop opioid treatment. We would recommend not completing the rest of the survey until you are ready to be seen at UW Headache Clinic. Please call the UW Headache Clinic with any further questions.

______ has more than 15 days of headache per month.

______ has ______ days of headache per month.

______'s headache started to become a problem ______ ______ ago.

HISTORY OF PRESENT ILLNESS:
______ is a delightful ______ year old ______ referred by ______ for evaluation of difficult to treat headache symptoms.

______'s first headache(s) occured when ______ was ______ years old. Headaches started to become a problem about ______ ______ ago. ______ is having an average of ______ days of headache per month, including ______ days of severe headache per month. The average pain severity is ______/10. The most severe headaches are rated ______/10. The headaches often last ______ ______, occurring ______.

______ believes the headache symptoms are caused by "______." ______'s headache is described as: "______".

Current headache days per month: ______

Current severe headache days per month: ______

History of >15 headache days per month: ______

Visual symptoms:

Visual Aura Rating Scale:

Patient's total score: *** (at least 5 suggests migraine with aura)

Duration of visual symptoms 5-60 minutes: [visual_between_5_and_60]

Gradual development over at least 5 minutes : ______

Scotoma: ______

Zig-zag line (fortification): ______

Unilateral: ______

Migraine with aura diagnosis ***

Autonomic symptoms:

Unilateral: ______,

Bilateral: ______

Headache with cough/exertion/Valsalva:______

Positional headache: ______

Dizziness with or without headache: ______

Neck pain/component to headache: ______

Triggers: ______

Number of caffeinated beverages per week: ______

Do you have difficulty with sleep? ______

______

Exercise (minutes/week): ______

History of head trauma: ______

Headache worse after trauma: ______

Cutaneous allodynia: ______

Family history of headaches: ______

Previously seen by: ***

VARS score

View equation

______ has seen the following previous providers prior to this appointment: ______

______

______

______

______

______ reports they are currently treating headache or other type of pain with opioids.

GOAL(S) OF THE VISIT IN THE NEUROLOGY HEADACHE CLINIC.
______ has the following goals for this visit:

Understand the cause of the pain

Discuss headache management

Better understand diagnosis (what is causing the headache and other symptoms)

______ is worried about having a brain tumor

______ is worried about having other disease causing the headache

______ would like to ask a specific treatment

TREATMENT PREFERENCE(S).
______ prefers the following treatment options:

Preventive prescription medication

Acute prescription medication

Supplements, herbs, or vitamins

BOTOX

Other non-medication procedures (e.g. nerve blocks)

Biofeedback or meditation

Hypnosis

Stress management

______

______ is interested in learning about new medications and other new treatments.

TREATMENT MODALITIES.
______ is willing to participate in the following treatment modalities:

Change current medication(s)

Exercise

Change diet

Learn meditation

Decrease stress

Learn relaxation techniques

Not ready to make change(s) at this time.

CONCERNS REGARDING CHANGES IN HEADACHE AND RELATED SYMPTOMS.
______ is concerned that the headache have changed in the following qualities:

The headaches have increased in their severity

The headaches are more intense

There are visual changes associated with the headaches

There is numbness associated with the headaches

There is weakness in arm(s) or leg(s) associated with the headaches

Problems with memory

There are other non-headache symptoms such as dizziness and vertigo

______

HEADACHE LOCATION:

Eyes

Forehead

Temple(s)

Face

Back of the head/ occipital area(s)

Neck

Holocephalic (global pain)

______

LATERALITY OF HEADACHE:

Right side

Left side

Bilateral

Always unilateral

Unilateral, not side locked

QUALITY OF HEADACHE PAIN

Pulsating/throbbing

Pressure

Tension

Sharp

Stabbing

Dull

Burning

______

HEADACHE TRIGGERS.
______ has the following headache triggers:

Stress

Menstrual period

Change in sleep

Skipped meals, thirst or dehydration

Food triggers such as cheese, chocolate, MSG, and other food triggers

Alcohol (for example, red wine)

Exercise and physical exertion

Visual hallucination(s)

Mental exertion (like solving a math problem)

Change in weather

Bright lights

Environment over stimulation: glare, odors and other

Not known

Diplopia (temporary)

______

VISUAL CHANGE(S) BEFORE OR DURING HEADACHE

No visual changes during or before headache

Seeing zigzag lines

Temporary blind spot (scotoma)

Blurred vision

Seeing visual hallucinations

Seeing bright lights

Temporary double vision

Seeing heat waves

______

ASSOCIATED HEADACHE SYMPTOMS.

______ has no associated symptoms such as light or sound sensitivity, nausea or vomiting.

Nausea/vomiting

Light sensitivity

Sound sensitivity

Numbness

Weakness

Dizziness

Fatigue/ low energy

Neck stiffness or tenderness

______

AUTONOMIC SYMPTOMS

Eye tearing ipsilateral side of headache

Bilateral eye tearing

Nasal congestion during headache

Bilateral nasal congestion during headache

Redness of the eye ipsilateral to headache

Redness of both eyes

Eyelid swelling

Forehead and facial sweating

Drooping eyelid

Change in normal pupil size (one pupil smaller)

A sense of restlessness or agitation

No autonomic symptoms during headache

EXACERBATION OF HEADACHES.
______ feels that the headaches are worse with:

Bright light or glare

Loud sounds

Strong smells

Physical exertion

Mental exertion

Being at work

Eye strain

Computer work

______

The patient has not identified anything that exacerbates the headache.

HEADACHE RELIEF.
______ finds the following to be helpful in relieving headaches:

______ has not found significant relief using medications, exercise, complementary therapies, and avoidance of headache triggers such as environmental stimuli.

Medications

Avoiding dehydration

Exercise

Sleep (at night or nap)

Rest

Avoiding bright lights, loud sounds, certain smells

Avoiding food triggers

Staying at home and not working

______

MEDICATIONS TRIED

ACUTE MEDICATIONS

Acetaminophen (tylenol)

______ is currently taking Acetaminophen (Tylenol) ______ days per week

Ibuprofen (Motrin/Advil)

______ is currently taking Advil/ibuprofen ______ days per week

Naproxen (Aleve/Naprosyn)

______ is currently taking Aleve/naproxen ______ days per week

Aspirin

Ketorolac (Toradol/Sprix)

Ketoprofen

Diclofenac (Cambia)

Celebrex (Celecoxib)

Excedrin

______ is currently taking Excedrin ______ days per week

Butalbital (Fioricet)

Midrin

Methylprednisolone (Medrol Dose Pack)

Prednisone (Prednisolone)

Imitrex (Sumatriptan)

______ is currently taking Sumatriptan ______ days per week

Maxalt (Rizatriptan)

______ is currently taking rizatriptan ______ days per week

Naratriptan(Amerge)

Almotriptan( Axert)

Frovatriptan (Frova)

Eletriptan (Relpax)

Zolmitriptan (Zomig)

Metoclopramide (Reglan)

Prochlorperazine (compazine)

Promethazine (Phenergan)

Ondansetron (Zofran)

Diphenhydramine (Benadryl)

DHE (Migranal)

Tramadol (Ultram/Ultracet)

Tylenol #3

Morphine

Dilaudid (Hydromorphone)

222's

Vicodin (hydrocodone and acetaminophen)

______ is currently taking vicodin ______ days per week

Marijuana

______ is currently taking marijuana ______ days per week

______, ______

PREVENTIVE MEDICATIONS FOR HEADACHE

______ states they are generally sensitive to medications.

______ is currently not using any preventive medication(s) for headache(s).

Inderal (propranolol)

Depakote (valproate)

Topamax (topiramate)

Neurontin (gabapentin)

Lyrica (pregabalin)

Elavil (Amitriptyline)

Celexa (citalopram)

Cymbalta(Duloxetine)

Verapamil

Levetiracetam (Keppra)

Lamotrigine (Lamictal)

Zonisamide (Zonegram)

Nortriptyline (Pamelor)

Fluoxetine (Prozac)

Sertraline (zoloft)

Venlafaxine (Effexor)

Cyproheptadine

Metoprolol

Lisinopril

Acetazolamide

BOTOX

Occipital Nerve Block

CEFALY

______

PREVENTIVE MEDICATIONS TRIED THAT HAVE BEEN GIVEN ADEQUATE TRIAL FOR HEADACHE
(At least 3 months at a therapeutic dose)
***

THERAPIES TRIED

Physical Therapy

Massage Therapy

Acupuncture

Biofeedback

Hypnotherapy

Meditation

CEFALY Device for Migraine Treatment

Diet
______

Exercise
______

Naturopathic Medicine

Homeopathic Medicine

Craniosacral Therapy

Aromatherapy

Chiropractic

______

______ has not tried other therapies for headache prevention.

SUPPLEMENTS

Magnesium

CoQ10

Riboflavin (Vit B2)

Vitamin B12

Vitamin B Complex

Feverfew

Butterbur

Melatonin

Turmeric

SAMe

Marijuana

______

______ has not tried any other supplements for headache

NEUROIMAGING/ED:

______ reports they have had CT scan of the brain on ______. Results of the scan per ______ are: ______.

______ reports they have never had CT head.

______ reports they have had MRI of the brain on ______. Results of the scan per ______ are: ______.

______ reports they have never had MRI of the brain.

______ reports they have sought care in the ER on ______ at ______.

______ reports they have never sought care in the ER for headache.

SOCIAL HISTORY:
______ has ______.
______'s overall health is: ______.
In the past 3 months, headaches have interfered with ______'s normal work (outside and home): ______.

Currently works in ______ about ______ per week.

On average, ______ misses about ______ days of work per month.

______ does not miss work in an average month.

Currently chooses not to work.

Currently not working, on disability.

Currently not working due to labor and/or industry claim.

Currently not working, on FMLA.

Currently not working, in school.

Currently not working, actively looking for work.

Currently retired, no longer working.

Minutes per week of moderate to vigorous exercise: ______
Servings of carbohydrates per day: ______
Servings of vegetables and fruit per day: ______

______ smokes ______ cigarette(s) per day.

______ does not smoke.

______ drinks ______ cups of caffeinated beverages per week.

______ does not drink caffeinated beverages.

______ states that they drink ______ alcoholic beverages per week.

______ does not drink alcohol.

______ does not have difficulty sleeping.

______ has difficulty sleeping. See attached REDCap survey responses for more detail.

ADDITIONAL DATA:
PHQ-4 score is ______
PSS score is ______
STOP BANG score is ______

Consider referral to sleep clinic to rule out RLS

REVIEW OF SYMPTOMS, reviewed with ______ today and uploaded from RedCap survey.

Positives include:

Headache

Dizziness

Light-headedness

Numbness

Seizure

Difficulty speaking

Fainting

Muscle weakness

Tremor

Confusion

Difficulty concentrating

Depressed mood

Anxious mood

Trouble sleeping

Eye pain

Photophobia

Eye redness

Negative for dizziness, headache, light-headedness, numbness, seizure, difficulty speaking, fainting, muscle weakness, tremor.

Negative for trouble sleeping, confusion, decreased ability to concentrate, depressed mood, anxious mood.

Otherwise 10 ROS negative.

PAST MEDICAL HISTORY

States "I do not have any other health conditions" on REDCap Survey

Depression

Anxiety or panic disorder

PTSD

Bipolar

HTN

Sleep Apnea

Hyperlipidemia

MI

Arrhythmia

Other heart disease

Hypothyroidism

Stroke or TIA

Seizure

Fibromyalgia

Chronic fatigue syndrome

______

PAST SURGICAL HISTORY

Stated "I have never had surgery in the past" on REDCap survey

Spine surgery

Brain surgery

Appendectomy

Cholecystectomy

______

FAMILY MEDICAL HISTORY

Father with headache

Mother with headache

Brother with headache

Sister with headache

Son with headache

Daughter with headache

Cousin with headache

Paternal grandfather with headache

Paternal grandmother with headache

Maternal grandfather with headache

Maternal grandmother with headache

Paternal uncle with headache

Paternal aunt with headache

Maternal uncle with headache

Maternal aunt with headache

Father with seizure

Mother with seizure

Brother with seizure

Sister with seizure

Son with seizure

Daughter grandfather with seizure

Cousin with seizure

Paternal grandfather with seizure

Paternal grandmother with seizure

Paternal uncle with seizure

Paternal aunt with seizure

Maternal uncle with seizure

Maternal aunt with seizure

Scheduled for first appointment?

Yes

No

Age

View equation

Birth Year

View equation

1D. email

* must provide value

1E. What is your gender?

* must provide value

male

female

gender neutral

other

Please provide us with any preference of gender pronoun or other information that would be helpful

1F. Were you referred to us by another healthcare provider, or are you self-referred?

* must provide value

Referred by another provider

Self-referred

1G. What is the name of the medical provider who referred you to our clinic?

* must provide value

2A.What goals are important for you to discuss during this visit? Select all that apply.

* must provide value

Understand why I am having pain

Better understand my current diagnosis

Discuss headache treatment

I am worried that I might have a brain tumor

I am worried about having other disease

I have a specific treatment I would like to ask about

Other

Please elaborate:

What other diagnosis are you worried about?

2B. What treatment options do you prefer? Please select all that apply.

* must provide value

Preventive prescription medication

Acute prescription medication

Supplements, herbs, or vitamins

BOTOX

Other non-medication procedures (e.g. nerve blocks)

Biofeedback or meditation

Hypnosis

Stress management

Other

Please elaborate:

* must provide value

2C. What are you interested in doing to achieve your goal(s)?

Change current medication(s)

Exercise

Change diet

Learn Meditation

Decrease stress

Learn relaxation techniques

None of the above

Other

What else are you interested in to achieve your goals?

2D. Are you interested in learning about new medications, or other new treatments?

* must provide value

Yes

No

Are you interested in participating in research studies?

* must provide value

Yes

No

Do you use a smart phone regularly?

* must provide value

Yes

No

What kind of smartphone are you currently using?

Apple iPhone

Android

Other

What model is your smartphone?
For example, iPhone 8 or Samsung Galaxy S10

Are you interested in using a smartphone app for headache monitoring?

* must provide value

Yes

No

2E. I think my problem is caused by:

* must provide value

Expand

Are you planning a pregnancy in the next 6 months?

* must provide value

Yes

No

Are you currently pregnant?

* must provide value

Yes

No

For how many weeks have you been pregnant?

* must provide value

What is the approximate delivery date?

* must provide value

M-D-Y

Since you became pregnant, have your headaches gotten worse?

* must provide value

Yes

No

Are you breastfeeding?

* must provide value

Yes

No

For how many months do you plan to continue to breastfeed?

* must provide value

2AA. What is the reason for your visit today?

Headache

Other

What is the other reason for your visit today?

3A. What is most concerning to you about your headache(s)?
Check all that apply.

My headaches have increased in severity

My headaches have increased in frequency

I am concerned about visual changes

I am concerned about numbness associated with the headaches

I am concerned about weakness in arm(s) or leg(s) associated with the headaches

I have new non-headache symptoms such as dizziness and vertigo

I have been having problems with my memory

I have exercise induced headache

I have sexual activity induced headache

I don't know

Other

Please elaborate:

Do you have dizziness (migraine vertigo) with or without a headache?

Vertigo any time

Vertigo triggered by movement

Constant imbalance

Movement-associated imbalance

Lightheadedness

None

Do you have headaches that occur only during Valsalva such as sneezing, coughing, exertion, or during a bowel movement?
The Valsalva maneuver is performed by moderately forceful attempted exhalation against a closed airway.

sneezing

cough

exertion

during bowel movement

no

Do you have a headache that is present only in a certain position?
A positional headache is characterized by pain in the back of the head that begins or worsens when standing up or sitting, and is eased or alleviated by lying down (typically within 30 minutes or less).
Or it can occur only with laying down

begins or worsens when standing up or sitting

begins or worsens when laying down

no changes in position cause headache worsening

3B. Have you been given a specific headache diagnosis from another provider?

* must provide value

Yes

No

Please elaborate:

Please state the diagnosis you were given.

* must provide value

How old were you when you had your first headache?
We are asking about any headache, not just the bad or most recent one(s).

3C. Do you get more than one type of headache?

Yes

No

3D. Is your current headache different from your typical headache?

* must provide value

Yes

No

Is this headache more severe than previous headaches?

* must provide value

Yes

No

Is this headache the worst you ever experienced?

* must provide value

Yes

No

Does this headache last longer than previous headaches?

* must provide value

Yes

No

Do you have any of the following symptoms occur with this headache?

* must provide value

Loss of vision

Numbness

Weakness

None of the above

3E. Have you had any history of head trauma (such as concussion, head injury)?

* must provide value

Yes

No

How did you injure your head?

* must provide value

Sports like football

Motor vehicle accident

Military

Fall/s

A hit to the head

Did the head trauma cause and/or worsen your headaches ?

* must provide value

Yes

No

Check all that apply:

Autoimmune disease (such as rheumatoid arthritis, lupus, or other)

Cancer

History of bone marrow or organ transplant

3F. Have you ever been diagnosed with an autoimmune disease (such as rheumatoid arthritis, lupus, etc), cancer or experienced a bone marrow or organ transplant?

* must provide value

Yes

No

Do you take any medications that decrease your immune system such as a steroid (prednisone) or immunosuppressant (such as tacrolimus)?

Yes

No

Please list medications:

4A. Please provide a brief description of your headache or headache related symptoms that you want us to evaluate (vertigo, visual loss or other).

* must provide value

Expand

4B. How long ago did your headache(s) become a problem?

* must provide value

less than 1 year ago

1 to 3 years ago

3 to 5 years ago

5 to 10 years ago

longer than 10 years ago

4C. How long ago was your very first headache (any type of headache)?

* must provide value

4D. How long ago did your headaches start being a problem?

* must provide value

days

months

years

How many ______ ago did your headaches start being a problem?

* must provide value

4E. Do you have headache 15 days a month or more? ( This includes any headache combination such as having migraines 8 days per month and having tension headache the rest of the days)

* must provide value

Yes

No

Have you ever had at least 15 days per month of any headache in your lifetime? This includes any headache type.

* must provide value

Yes

No

4F. How many days per month are you having any headache?

* must provide value

How many days have you experienced any kind of headache in the last 30 days?

How many days in the last 30 days have you had a severe headache?

4F. How many days per month are you having severe headaches?

* must provide value

4G. Do you ever have time(s) with no headache-related pain (even few minutes with no headache during the day)?

* must provide value

Yes

No

4H. What is the average severity of your headaches on a scale of 0-10, where 1 means "almost no pain" and 10 means "the worst headache or pain imaginable"?

* must provide value

0

1

2

3

4

5

6

7

8

9

10

4I. What is worst severity of your headaches on a scale of 0-10, where 1 means "almost no pain" and 10 means "the worst pain imaginable"?

* must provide value

0

1

2

3

4

5

6

7

8

9

10

4J. Which of these amounts of time best describes how long your headaches usually last?

* must provide value

seconds

minutes

hours

days

How many ______ do your headaches usually last?

* must provide value

4K. When in the day do your headaches usually occur? (morning, evening, etc.) Select all that apply.

* must provide value

all day long

morning

mid-day

afternoon

evening

wake me up from sleep

no specific time

4L. What is the best description of your headache? Please select all that apply.

* must provide value

Pulsating or throbbing

Pressure

Tension

Sharp

Stabbing

Dull

Burning

Other

Please describe:

* must provide value

4M. Where are the headaches that concern you most located? Please select all that apply.

* must provide value

Eye

Forehead

Temple

Face

Back of the head

Neck

All over

Other

Please describe:

* must provide value

4N. On which side does the headache pain occur? Please select all that apply

* must provide value

right side

left side

both sides

always on one side

changes sides

4L. Do you have any changes in vision before or during migraine? Please check all that apply.

seeing zigzag lines

temporary blind spot (scotoma)

blurred vision

seeing visual hallucinations

seeing bright lights

temporary double vision

seeing heat waves

other

none

Please describe other aura symptoms:

Is the duration of your visual symptoms (migraine aura) between 5-60 minutes ?

Yes

No

Do you visual symptoms (migraine aura) develop gradually over at least 5 minutes?

Yes

No

Do you see a blind spot in your vision with you have visual aura?

Yes

No

Do you see zig-zag lines with your visual aura?

Yes

No

Are your visual changes ) visual aura only on one side of your visual field (right or left predominantly)?

Yes

No

5A. Do you have any headache triggers? Please check all that apply.

* must provide value

stress

menstrual period

change in sleep

skipped meals, thirst or dehydration

food : cheese, chocolate, MSG, other

alcohol (for example, red wine)

exercise and physical exertion

mental exertion (like solving a math problem)

change in weather

environment over stimulation: glare, odors and other

exercise

sexual activity

I don't know

other

Please describe on which day of the menstrual cycle do you have a headache. Please check all that apply.

* must provide value

before period

during period

after period

Please state which food and or food additives cause your headache/s.

* must provide value

Please state what type, brand and amount of alcohol provokes your headache.

* must provide value

Please describe other triggers:

* must provide value

5B. What makes your headaches worse? Select all that apply.

* must provide value

bright light or glare

loud sounds

strong smells

physical exertion

mental exertion

being at work

nothing makes the headache worse

eye strain

computer work

exercise and exertion

sexual activity

other

Please describe:

* must provide value

5C. Do you have any other symptoms before or during the headache?

* must provide value

I have no other symptoms

Nausea/vomiting

Light sensitivity

Sound sensitivity

Numbness

Weakness

Dizziness

Fatigue/ low energy

Neck stiffness or tenderness

Other

Please describe:

* must provide value

Do you have neck pain?

Yes

No

Do you have allodynia? This is a condition in which pain is caused by a stimulus that does not normally elicit pain, like touching your skin.

Yes

No

Do you have any of these symptoms DURING the headache ONLY on the SAME SIDE as the headache?

Eye tearing

Nasal congestion

Eye redness

Eyelid swelling

Forehead and facial sweating

Drooping eyelid

Change in normal pupil size (one pupil smaller)

A sense of restlessness or agitation

None

Do you have any of these symptoms DURING the headache on BOTH SIDES?

Eye tearing

Nasal congestion

Eye redness

None

5D. Do any of the following help relieve your headache(s) ? Please select all that apply.

* must provide value

Nothing helps

Medications

Exercise

Sleep (at night or nap)

Rest

Avoiding bright lights, loud sounds, certain smells

Avoiding foods that can cause headache

Drinking water

Staying at home and not working

Other

Please describe:

* must provide value

Do you perceive that you are sensitive to medications?

Yes

No

Unsure

6A. Medication(s) to STOP headache
Do you take medication(s) to stop headache?

* must provide value

Yes

No

6.AA Medications to stop headache.

acetaminophen (Tylenol)

ibuprofen (Motrin/Advil)

Naproxen (Aleve/Naprosyn)

Aspirin

Ketorolac (Toradol/Sprix)

Ketoprofen (Relafen)

Diclofenac (Cambia)

Celebrex(Celecoxib)

Excedrin

Butalbital(Fioricet)

Midrin

Methylprednisolone (Medrol Pack)

Prednisone/Prednisolone

Sumatriptan (Imitrex/Treximet)

Rizatriptan(Maxalt)

Naratriptan(Amerge)

Almotriptan(Axert)

Frovatriptan(Frova)

Eletriptan(Relpax)

Zolmitriptan(Zomig)

Metocloprimide(Reglan)

Prochlorperazine(Compazine)

Promethazine (Phenergan)

Ondansetron(Zofran)

Diphenhydramine(Benadryl)

DHE(Migranal)

Tramadol(Ultram/Ultracet)

Tylenol #3/Tylenol with Codeine

Morphine

Dilaudid (Hydromorphone)

Vicodin

Marijuana

222"s

Other

Please name the other medication not listed:

Currently taking
(more than 4 days a month)

Currently taking
(less than 4 days a month)

Taken in the past

Side effect(s)

Effective

Tylenol (acetaminophen)

Motrin (Ibuprofen)/ Advil

Aleve (naproxen)

Aspirin

Ketorolac(Toradol/Sprix)

Ketoprofen(Refafen)

Diclofenac (Cambia)

Celebrex(Celecoxib)

Excedrin

Butalbital(Fioricet)

Midrin

Methlprednisolone (Medrol Dose Pack)

Prednisone(Prednisolone)

Imitrex (Sumatriptan)

Maxalt (Rizatriptan)

Naratriptan(Amerge)

Almotriptan(Axert)

Frovatriptan(Frova)

Eletriptan(Relpax)

Zolmitriptan(Zomig)

Metoclopramide(Reglan)

prochlorperazine (compazine)

promethazine(Phenergan)

ondansetron (Zofran)

Diphenhydramine(Benadryl)

D.H.E. (Migranal)

Tramadol (Ultram/Ultracet)

Tylenol #3 (Tylenol with codeine)

Morphine

Dilaudid(Hydromorphone)

Vicodin

Marijuana

Other medications not listed:

How many days per week are you taking Tylenol?

How many days per week are you taking Ibuprofen/Advil?

How many days per week are you taking Aleve/Naproxen?

How many days per week are you taking aspirin?

How many days per week are you taking ketorolac(Toradol)?

How many days per week are you taking ketoprofen(Relafen)?

How many days per week are you taking diclofenac (Cambia)?

How many days per week are you taking celebrex(Celecoxib)?

How many days per week are you taking Excedrin?

How many days per week are you taking butalbital (Fioricet/Fiorinal)?

How many days per week are you taking Midrin ( Isometheptene Mucate USP, 65 mg and Dichloralphenazone USP, 100 mg, and Acetaminophen USP, 325 mg)

How many days per week are you taking Methylprednisolone (Medrol pack)?

How many days per week are you taking prednisone (prednisolone)?

How many days per week are you taking Imitrex/sumatriptan (or Treximet)?

How many days per week are you taking Maxalt/rizatriptan?

How many days per week are you taking naratriptan(Amerge)?

How many days per week are you taking almotriptan(Axert)?

How many days per week are you taking Frovatriptan(Frova)?

How many days per week are you taking Relpax/eletriptan?

How many days per week are you taking Zolmitriptan (Zomig)?

How many days per week are you taking Metoclopramide (Reglan)?

How many days per week are you taking Prochloraperazine (Compazine)?

How many days per week are you taking Promethazine (Phenergan)?

How many days per week are you taking Odansetron (Zofran)?

How many days per week are you taking Diphenhydamine (Benadryl)?

How many days per week are you taking DHE (Migranal)?

How many days per week are you taking tramadol (Ultram/Ultracet)?

How many days per week are you taking Tyenol #3 (Tyenol with codiene)?

How many days per week are you taking Morphine?

How many days per week are you taking Hydromorphone (Dilaudid)?

How many days per week are you taking Hydrocodone with Acetaminphen (Vicodin)?

How many days per week are you taking marijuana?

How many days per week are you taking this other medication?

Other medications not listed:

* must provide value

Helpful

Not helpful

Caused side effects

Tylenol (acetaminophen)

Ibuprofen (Motrin, Advil)

Aleve (naproxen)

Imitrex (sumatriptan)

Maxalt (rizatriptan)

Relpax (eletriptan)

D.H.E.

Tramadol

Fiorinal or Fioricet (butalbital)

Vicodin

Marijuana

Other medication not listed

Please check any medication listed below that you have taken in the past OR are currently taking for headache OR other condition.

I am not currently taking medications to prevent headaches

Inderal (Propanolol)

Depakote (Valproate)

Topamax (Topiramate)

Neurontin (Gabapentin)

Lyrica (Pregabalin)

Elavil (Amitriptyline)

Celexa (Citalopram)

Cymbalta (Duloxetine)

Verapamil

Levetiracetam (Keppra)

Lamotrigine (Lamictal)

Zonisamide (Zonegram)

Nortriptyline (Pametor)

Fluoxetine (Prozac)

Sertraline (Zoloft)

Venlafaxine (Effexor)

Cyproheptadine (Periactin)

Metoprolol (Toprol)

Lisinopril (Zestril)

Acetazolamide (Diamox)

Doxycycline

Minocycline

BOTOX (onabotulinum toxin) for migraine

Occipital nerve block

CEFALY

Marijuana daily for headache prevention

Other medications not listed

How long did you take this medication?

Less than 3 months

Longer than 3 months

Currently taking

Helpful

Not helpful

Causing side effect(s)

Not currently taking medications to prevent headache

Inderal (propranolol)

Depakote (valproate)

Topamax (topiramate)

Neurontin (gabapentin)

Lyrica (pregabalin)

Elavil (Amitriptyline)

Celexa (Citalopram)

Cymbalta (Duloxetine)

Verapamil

Levetiracetam (Keppra)

Lamotrigine (Lamictal)

Zonisamide (Zonegram)

Nortriptyline (Pametor)

Fluoxetine (Prozac)

Sertraline (Zoloft)

Venlafaxine (Effexor)

Cyproheptadine (Periactin)

Metoprolol (Toprol)

Lisinopril (Zestril)

Acetazolamide (Diamox)

Doxycycline

Minocycline

BOTOX (onabotulinum toxin) for migraine

Occipital nerve block

CEFALY

Marijuana daily for headache prevention

Other medication not listed

Other medications not listed:

* must provide value

Have taken in the past

Helpful

Not helpful

Caused side effects

Inderal (propranolol)

Depakote (valproate)

Topamax (topiramate)

Neurontin (gabapentin)

Lyrica (pregabalin)

Elavil (amitriptyline)

Celexa (citalopram)

Cymbalta

Verapamil

BOTOX (onabotulinum toxin) for migraine

Occiptial nerve block

Cefaly device

Marijuana daily for prevention

Other medication not listed

Please state the other medication not listed:

Currently

In the past

Helpful

Not helpful

Side effect(s)

Physical Therapy

Massage Therapy

Acupuncture

Biofeedback

Hypnotherapy

Meditation

Cefaly Device

Diet

Exercise

Naturopathic Medicine

Homeopathic Medicine

Craniosacral Therapy

Aromatherapy

Chiropractic

Other

None

What other therapy have you tried?

Expand

What kind of diet changes have you tried for headache prevention?

Expand

What kind of exercise have you tried and how often?

Expand

Currently taking

Have taken in the past

Helpful

Not helpful

Side effect(s)

Magnesium

CoQ10

Riboflavin (Vitamin B2)

Vitamin B12

Vitamin B Complex

Feverfew

Butterbur

Melatonin

Turmeric

SAMe

Marijuana

Other

None

Please elaborate:

* must provide value

6E. Have you ever gone to an emergency room for treatment of a headache?

* must provide value

Yes

No

What is the date of the last time you went to an emergency room for treatment of your headaches?

* must provide value

M-D-Y

What is the location of the emergency room you visited?

* must provide value

MRI Brain -provider to add

* must provide value

Normal Brain MRI

White matter changes

Abnormal Brain MRI with significant finding

Brain tumor

Not available (not done, no report)

other

6F. Have you ever had a CT/CAT(Computed tomography) scan of the brain?

* must provide value

Yes

No

What is the date of the last CT brain scan you had?

* must provide value

M-D-Y

What were the results of the last brain CT scan you had?

* must provide value

Expand

6G. Have you ever had an MRI (Magnetic Resonance Imaging) scan of the brain?

* must provide value

Yes

No

What is the date of the last brain MRI scan you had?

* must provide value

M-D-Y

What were the results of the last brain MRI scan you had?

* must provide value

Expand

7A. In general your health is:

Excellent

Very good

Good

Fair

Poor

7B. Does your headache limit you in the following activities?

Vigorous activities (running, lifting heavy objects, participating in sports)

Moderate activities (moving table, pushing a vacuum, playing golf)

Lifting or carrying groceries

Climbing several flights of stairs

Climbing one flight of stairs

Bending, kneeling, or stooping

Walking more than one mile

Walking several blocks

Walking one block

Bathing or dressing yourself

Does not interfere with any of these activities

7C. In the past 3 months, how much did your headache(s) interfere with your normal work (outside and housework)?

Not at all

A little bit

Moderately

Quite a bit

Extremely

7D. Do you get at least 7 hours of sleep per night most nights?

Yes

No

7E. Do you have any difficulty with sleep?

* must provide value

Yes

No

Do you have any problems that interfere with getting good sleep? Please select all that apply.

* must provide value

Insomnia

Trouble falling asleep

Trouble staying asleep

Waking up not feeling refreshed

Frequent awakening

Sleep apnea

Narcolepsy

Hypersomnia

other

When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement?

Yes

No

Do you SNORE loudly (louder than talking or loud
enough to be heard through closed doors)?

Yes

No

Do you often feel tired, fatigued, or sleepy during the daytime (such as falling asleep during driving or talking to someone)?

Yes

No

Has anyone observed you stop breathing or choking/gasping during your sleep ?

Yes

No

Do you have or are you being treated for high blood pressure?

Yes

No

Is your age over 50 years old?

Yes

No

Is your shirt collar size larger than 15.5 inches or larger than M (Medium)?

Yes

No

STOP BANG Score

View equation

STOP BANG Score No BMI

View equation

7F. Do you have depression or anxiety?

* must provide value

Yes

No

Please check the diagnosis that apply

* must provide value

major depression

depression

anxiety

bipolar disorder

mania

PTSD

8A. Have you been diagnosed with any of the following conditions?

* must provide value

I do not have any other health conditions

High blood pressure (hypertension)

Sleep apnea

High cholesterol (high fat or high lipids)

Heart attack

Arrhythmia

Other heart disease (if yes, specify what type)

Hypothyroidism

Stroke or TIA

Seizures or epilepsy

Fibromyalgia

Chronic fatigue syndrome

Depression

Bipolar disorder

Anxiety or panic disorder

PTSD

Other

Please other health conditions you have been diagnosed with:

* must provide value

8B. Have you had any surgeries in the past? Select all that apply.

* must provide value

I have never had surgery in the past

Spine surgery

Brain surgery

Appendectomy

Gallbladder surgery

Other

Please list other surgeries you have had in the past:

* must provide value

Do you have a family history of headache in any biological family member(s)?

Yes

No

Headache

Seizures

Dementia

Stroke

Aneurysm

Father

Mother

Brother

Sister

Son

Daughter

Cousin

Paternal grandfather

Paternal grandmother

Maternal grandfather

Maternal grandmother

Paternal uncle

Paternal aunt

Maternal uncle

Maternal aunt

I am adopted, no known family history:

9A. What is the highest degree or level of school you have completed?

* must provide value

no schooling completed

some high school, no diploma

finished high school

some college, no degree

finished college or university

some graduate work

Masters

Doctorate

Other

9B. Are you currently employed?

* must provide value

Yes

No

You communicated that you are not currently working. Please indicate any of the following options that may apply for your unemployment status:

Homemaker/stay at home parent/chose not to work

Disability

Labor and Industry leave or involved in labor dispute

Family Medical Leave or maternity/paternity leave

Currently in School

Currently looking for work

Retired

What type of work are you employed in?

* must provide value

On average how many hour do you work per week?

* must provide value

Under 10 hours

10 to 20 hours

20 to 40 hours

40

more than 40

more than 50

Have you missed any days of work due to headaches?

* must provide value

Yes

No

Approximately how many days of work do you miss per month?

* must provide value

9C. How many minutes per week do you get of moderate or vigorous exercise? (This includes very brisk walking, jogging, playing a sport, heavy cleaning, bicycling, and so on.)

* must provide value

9D. How many servings of wheat, potatoes, rice, or bread do you eat per day? This includes products such as bread and potato chips.

* must provide value

9E. How many servings of fruit and vegetables do you eat per day? This does not include products made with fruit or vegetables, such as fruit jam or pie.

* must provide value

9F. Do you smoke or use tobacco products?

* must provide value

Yes

No

How many cigarettes or cigarette-equivalents of other tobacco products do you consume per day?

* must provide value

9G. Do you consume alcoholic beverages?

* must provide value

Yes

No

How many alcoholic beverages do you consume per week?

* must provide value

9H. Do you consume caffeinated beverages? This includes coffee, tea, energy drinks, and certain sodas.

* must provide value

Yes

No

How many caffeinated beverages do you consume per week?

* must provide value

9I. Do you use recreational or street drugs? This includes drugs such as marijuana, cocaine, heroin and meth, and others.

* must provide value

Yes

No

How many days per week do you consume street drugs or marijuana?

* must provide value

10 A. Please check any of the symptoms that you are currently experiencing or symptoms you may experience during headache.

* must provide value

Dizziness

Headache

Light-headedness

Numbness

Seizure

Difficulty speaking

Fainting

Muscle weakness (not fatigue)

Tremor

None of the above

10B. Choose any of the following symptoms you are currently or recently experiencing:

* must provide value

Confusion

Decreased ability to concentrate

Depressed mood

Anxious mood

Trouble sleeping

None of the above

10C. Do you have any symptoms related to your eyes such as visual loss, redness of eyes, or visual blurring?

* must provide value

Yes

No

Please check any symptoms you are currently experiencing.

* must provide value

Eye pain

Eye redness

Sensitivity to light

Change in vision

Loss of vision in one eye

None of the above

10D. Do you have any symptoms related to your ears, nose or throat?

* must provide value

Yes

No

Please check any symptoms you are currently experiencing.

* must provide value

Nasal congestion

Dental problem (current)

Fluid leaking from the ear

Ear pain

Loss of hearing

Sinus pressure

Tinnitus (ringing in the ear)

None of the above

10E. Are you having any problems with your heart or circulation such as chest pain?

* must provide value

Yes

No

Please check any of the symptoms you are currently experiencing.

* must provide value

Chest Pain

Palpitations

10F. Are you having any difficulty with your lungs or with breathing such as shortness of breath, COPD or chronic cough?

* must provide value

Yes

No

Please check any of the symptoms that you are currently experiencing.

* must provide value

Periods of time when you stop breathing (apnea)

Shortness of breath

Daily cough

10G. Are you having any problems with your genitals (private parts) or urinary tract such as frequent urination ?

* must provide value

Yes

No

Please check all the symptoms that you are experiencing.

* must provide value

Frequent Urination

Urinate more than twice a night

Sexual Issue

None of the above

10H. Are you having any problems with arthritis, back pain, or joint pain?

* must provide value

Yes

No

Please check all the symptoms that you are experiencing.

* must provide value

Arthralgias (joint pain)

Myalgias (muscle pain)

Neck pain

Neck stiffness

Back pain

None of the above

Are you having any problems with your breasts or with menstrual periods?

* must provide value

Yes

No

Please check all the symptoms that you are experiencing.

* must provide value

Lump or Discharge of Breast

Heavy Periods

Painful Periods

None of the above

10 I. Have you had any fevers, chills, weight changes, or difficulty with cold or hot weather?

* must provide value

Yes

No

Please check any symptoms you are currently having.

* must provide value

Chills

Fatigue

Fever

Unexplained weight loss or gain

Sweating

Intolerance of cold

Intolerance of heat

None of the above

10 J. Are you having any problems with allergies or with your immune system?

* must provide value

Yes

No

Please check any of the symptoms that you are experiencing.

* must provide value

Seasonal Allergies

None of the above

Problems with immunity

10K. Are you having any problems with bleeding or with your lymph nodes?

* must provide value

Yes

No

Please check any of the symptoms that you are experiencing.

* must provide value

Enlarged Glands

Easy bruising or bleeding

10L. Are you having any problems with your stomach or digestion such as nausea, stomach pain, reflux or constipation?

* must provide value

Yes

No

Please check any of the symptoms that you are experiencing.

* must provide value

Constipation

Diarrhea

Nausea

Vomitting

11A. What is the name of your primary care provider (PCP)? Answer "none" if you have no PCP.

* must provide value

11B. Are there any other providers who need to receive a medical report from our clinic? If so, please provide their names, phone numbers, and addresses. Can answer "none" if there are no providers who need reports.

* must provide value

Expand

11C. Have you already seen any neurologist for management of your headache?

* must provide value

Yes

No

Neurologist #1

* must provide value

Neurologist #2

Neurologist #3

Neurologist #4

Neurologist #5

Neurologist #6

Neurologist #7

Neurologist #8

Neurologist #9

Neurologist #10

11D. Have you seen any healthcare providers for management of your headache that are not neurologists?

* must provide value

Yes

No

11E. How many other providers have you seen for your headache?

* must provide value

Never

Almost Never

Sometimes

Fairly Often

Very Often

In the last month, how often have you been upset of something that happened unexpectedly?

In the last month, how often have you felt that you were unable to control the important things in your life?

In the last month, how often have you felt nervous and "stressed"?

In the last month, how often have you felt confident about your ability to handle your personal problems?

In the last month, how often have you felt that things were going your way?

In the last month, how often have you found that you could not cope with all the things that you had to do?

In the last month, how often have you been able to control irritations in your life?

In the last month, how often have you felt that you were on top of things?

In the last month, how often have you been angered because of things that were outside of your control?

In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

PSS Total

View equation

Not at all

Several days

More than half the days

Nearly every day

Feeling nervous, anxious or on edge

Not being able to stop or control worrying

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

PHQ 4 Total

View equation

In the past 7 days,
My thinking has been slow

* must provide value

Never

Rarely (Once)

Sometimes (Two or three times)

Often (About once a day)

Very often (Several times a day)

In the past 7 days,
It has seemed like my brain was not working as well as usual

* must provide value

Never

Rarely (Once)

Sometimes (Two or three times)

Often (About once a day)

Very often (Several times a day)

In the past 7 days,
I have had to work harder than usual to keep track of what I was doing

* must provide value

Never

Rarely (Once)

Sometimes (Two or three times)

Often (About once a day)

Very often (Several times a day)

In the past 7 days,
I have had trouble shifting back and forth between different activities that require thinking

* must provide value

Never

Rarely (Once)

Sometimes (Two or three times)

Often (About once a day)

Very often (Several times a day)

In the past 7 days,
I have had trouble concentrating

* must provide value

Never

Rarely (Once)

Sometimes (Two or three times)

Often (About once a day)

Very often (Several times a day)

In the past 7 days,
I have had to work really hard to pay attention or I would make a mistake

* must provide value

Never

Rarely (Once)

Sometimes (Two or three times)

Often (About once a day)

Very often (Several times a day)

In the past 7 days,
I have had trouble forming thoughts

* must provide value

Never

Rarely (Once)

Sometimes (Two or three times)

Often (About once a day)

Very often (Several times a day)

In the past 7 days,
I have had trouble adding or subtracting numbers in my head

* must provide value

Never

Rarely (Once)

Sometimes (Two or three times)

Often (About once a day)

Very often (Several times a day)

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