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  1. Surveys
  2. 2013
  3. March
  4. H
  5. Headache 6WFU
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Thank you again for agreeing to participate in our study. It will take less than 10 minutes to complete the questionnaire.

Your participation in this study is completely voluntary and your survey responses will be strictly confidential. If you have questions at any time about the survey, you may contact Nurse Betty at 210-916-0731.
 
 
Please enter your survey code:
   
 
 
 
1)In the time since your first visit, how would you rate your headache control?
 
Much worse
 
A little worse
 
Not better or worse
 
A little better
 
Much better
 
 
 
2) In the time since your first visit, how many days have you had a headache?
 
Every day
 
Not every day. Please enter your average number of headache days PER MONTH:
 
 
 
 
3) In the time since your first visit, have you identified any triggers for your headaches? (Check all that apply)
 
Exercise
 
Hunger
 
Dehydration
 
Certain foods
 
Menstrual periods
 
Stress
 
Other (please specify):
 

 
 
 
4) Are you currently taking any medications for headache? This includes both medications prescribed by a doctor or that can be bought at a pharmacy. Please check all that apply.
 
No, I am not taking any medication specifically for headaches.
 
Yes, I am taking medication as needed for headache pain.
 
Yes, I am taking a daily medication to prevent headaches.

 
 
 
5) Do you feel that your medication is working well to control your headaches?
 
Yes
 
No
 
N/A (I am not taking medications for headaches.)
 
 
 
6)Please list any side effect(s) you may be experiencing from your medications:
   
 
 
7) Please describe how your headaches have affected school and other activities in the past 3 months:
# of days(in the past 3 months)
a) How many full days of school did you miss due to headaches?
b) How many partial days of school did you miss due to headaches? *Do not include full days counted in question 7a
c) How many days did you function at less than half your ability in school because of a headache? *Do not include full or partial days counted in question 7a or 7b
d) How many days were you not able to do things at home (i.e., chores, homework, etc.) due to a headache?
e) How many days did you miss other activities due to headaches (i.e., play, go out, sports, etc.)?
f) How many days did you participate in these activities, but functioned at less than half your ability? *Do not include days counted in question 7f
 
 
 
Please use this space for any additional comments or questions. We welcome your feedback or suggestions to improve our clinic!
   
 
Thank you for participating!
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