Required:	Age   Sex Male Female
1.	Did you ever experience a similar headache previously?	Yes No Unknown/not applicable
2.	Where is headache located?	A. In the back of the head, forehead, neck, or shoulders B. Surrounding the head, generalized, or tight "as in a vise" C. One-sided D. Involving the face or teeth E. A and/or B F. None of the above G. Unknown/not applicable
3.	Quality or type of headache?	A. Throbbing or pulsating B. Pounding or aching C. Squeezing D. Sudden or lightning-like E. Other F. Unknown/not applicable
4.	How long have you experienced this type of headache?	A. Months or years B. Weeks C. Two-10 days D. 24-48 hours E. Less than 24 hours F. Unknown/not applicable
5.	Is this your "worst headache ever"?	Yes No Unknown/not applicable
6.	How long do headaches usually last if untreated?	A. Less than 2-3 hours. B. Up to 8 hours C. 8-24 hours or longer D. Unknown/not applicable
7.	Are your headaches related to any of the following?	A. Stress, tension, or nervousness B. Sexual activity, colds, allergies, eyestrain, or exertion C. Eating ice cream or taking cold drinks D. Changes in weather or barometric pressure E. No known causal relationship F. Unknown/not applicable
8.	What answer best describes frequency of headaches?	A. One to several times a month B. One or more times a week C. Daily or several times daily D. First time headache E. Attacks occur in "clusters" for days or months. F. Unknown/not applicable
9.	Warning signs present?	A. Visual disturbances, flashing lights, stars, blind spots, zigzag lines, etc. B. Speech disturbance, distortions of size or space C. Tingling, numbness, weakness of arm or leg, or mental confusion D. One or more of above E. None of above F. Unknown/not applicable
10.	Nausea, vomiting or diarrhea with headaches?	Yes No Unknown/not applicable
11.	Have you had any recent visual changes or visual loss in one or both eyes?	Yes No Unknown/not applicable
12.	Are headaches characterized by:	A. Severe stabbing pain behind one eye with tearing and/or redness B. Drooping or swelling of one eyelid C. Scalp tenderness, especially when combing the hair, lying on a pillow, wearing a hat or glasses? D. A and B E. None of above F. Unknown/not applicable
13.	Is there severe restlessness or pacing the floor, or do you ever rock your head or body during one of these headaches?	Yes No Unknown/not applicable
14.	During headache is there extreme sensitivity to light, sound, or smell?	Yes No Unknown/not applicable
15.	Is there any family history of migraine?	Yes No Unknown/not applicable
16.	Do you perform any of the following at work or elsewhere?	A. Sit at a computer terminal or watch TV for hours at a time B. Sit behind the wheel for long periods of time, commuting, driving any vehicle, etc. C. Lifting or any heavy physical labor involving arms, shoulders, or upper body, including heavy housework, gardening, etc. D. None of above E. Unknown/not applicable
17.	Any recent fever associated with a cold, respiratory infection, or nasal congestion?	Yes No Unknown/not applicable
18.	Is headache milder in the morning, increasing throughout the day?	Yes No Unknown/not applicable
19.	Does chewing produce pain, is opening jaw restricted, or is jaw noisy while chewing?	Yes No Unknown/not applicable
20.	Do you grind your teeth at night or do you wake up with a sore jaw or headache?	Yes No Unknown/not applicable
21.	Is headache more of a burning or jabbing sensation involving the surface of the scalp and face?	Yes No Unknown/not applicable
22.	History of severe high blood pressure (hypertensive) attacks leading to immediate medical treatment?.	Yes No Unknown/not applicable
23.	History of brain tumor or stroke?	Yes No Unknown/not applicable
24.	Are headaches accompanied by changes in personality or mental functioning?	Yes No Unknown/not applicable
25.	Recent onset of seizures or localized muscle weakness?	Yes No Unknown/not applicable
26.	Any head injury with loss of consciousness (concussion) in last few weeks?	Yes No Unknown/not applicable
27.	Recent fever with stiff neck with or without nausea and vomiting?	Yes No Unknown/not applicable
28.	Do you have any chronic lung, urinary tract, skin, or other infection such as AIDS, Lyme disease, Tb, etc.?	Yes No Unknown/not applicable