History of Headaches Prior to COVID-19 Please enable JavaScript in your browser to complete this form.Date Does Anyone in Your Family Have or had:Heart DiseaseHeart AttackStrokeHeart FailureHigh Blood PressureDiabetesMigraine Headaches Brain CancerHow Many Hours a Night Do You Sleep?Do You Have Trouble Falling Asleep?YesNoDo You Have Trouble Staying Asleep?YesNoDo You Eat Breakfast in the Morning?YesNoDo You Eat Lunch Each Day?YesNoOn Average How Many Caffeinated Drinks Do You Consume in a Day (Coffee, Tea, Soda, ectc.) On Average How Many Alcoholic Drinks Do You Consume in a Day (Mixed, Beer, Wine, etc.)?Do You Smoke?YesNoDo You Smoke-Consume THC or other drugsYesNoQuestions Concerning Stress & HeadachesDo You Manage Stress Well?YesNoStress Level At Work?LowMediumHighVery HighUnemployedRetiredHow Do You Manage Stress? (Check All That Apply)ExerciseSleep/NapRelaxation TechniquesHobbiesSpiritual Activities/PrayerFamily RelationshipsSocial RelationshipsMedicationAlcoholPrior to COVID-19 Did You Suffer From Headaches?NoYes; from ChildhoodYes, as a TeenYes, 20's-40'sYes, 50's & 60'sYes, after Injury or IllnessIf You Had Regular Headaches Prior to COVID-19 Did Anything Cause Them?NoSpecific StressBright LightsInjuryIllnessMedicationAlcohol-Drugs(For Women) Onset of PeriodHormones or Birth Control PillsFrequency of Headaches Prior to COVID:N/ASeveral Times a DayDailySeveral Times a WeekSporadically-MonthlyRarely-Few Times a YearHas the Intensity of Your Headaches Increased Over Time?N/ANoYesThey are more frequent during:WeekdaysWeekendsSpringSummerFallWinterHow Do Headaches Begin?N/AGraduallySuddenlyVariesHeadaches Being:N/AMorningAfternoonEveningNightIf You Were to Rate Your Average Headache Pre-COVID, How Disabling Were They?Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10On a scale of 1-10 rate the intensity of your headachesHow Long Do Your Headaches Last?N/AMinutesHour or Less1-2 HoursGreater Than 2 HoursLocation of HeadachesRight SideLeft SideBoth SidesFrontalBack of HeadBehind EyesBack of NeckAlternatesWhole HeadDescribe PainDullBandingExplodingThrobbingStablingDullDid You Notice Anything Preceding the Headache?Mood changes Personality changes Change in appetiteFood cravingsNeck painFatigue Do Any of These Accompany Your Headaches?AuraZig Zag PatternsNumbnessDizzinessBlurry VisionUpset StomachVomitingFatiguePartial ParalysisEye TearsMood ChangeRunny-Stuffy NoseSubmit