Post Surgery Migraine Headache Questionnaire - Bahman Guyuron, MD - Zeeba Clinic

Patient's name *

Date

Following Surgery, how many migraine headaches did you have have last month?

How many regular headaches did you have last months?

Do you have numbness in any area of the face? Please explain:

If you had migraine, how long did your migraine headaches last?

How painful are your headaches in the score of 1-10, 10 being most sever headache?

Was there any change in the location or characteristics of the pain

NoDo not have painYes

If yes, please explain:

Where does you headache start from?

Left
Behind the eyeAbove the eyebrowBack of the headTemple

Right
Behind the eyeAbove the eyebrowBack of the headTemple

Does headache awaken you at night?
NeverOccasionallyOften

Do you have any of these symptoms before or during headache?

Does any of these bring your migraine or make them worse?

Do any of these make your headache better?

If you are female, Do any of these change your headache?

Menstrual periodsBirth control pillsPregnancyHormonal medication

Was there any change on the amount and dosage of the medications for migraine headache?

How many day of work/school do you loose in a month?

To what extent migraine headache affects your life?
NoneVery littleModerateExtremely