Headache Questionnaire

Head InjurySlept too much or too littleDuring Emotional StressAfter Emotional StressDepression or AnxietyPhysical ActivityCan’t Fall AsleepCan’t Maintain SleepErect PositionBending OverStaining or CoughingOtherSexual Activity

Foods

Medications

Head InjurySlept too much or too littleDuring Emotional StressAfter Emotional StressDepression or AnxietyPhysical ActivityCan’t Fall AsleepCan’t Maintain SleepErect PositionBending OverStaining or CoughingOtherSexual Activity

Foods

Medications

YesNo

RestActivityDarknessQuiet

Cigarettes

Alcohol

Coffee

DepressedAnxiousNone

YesNo