Sophos Georgio Geroulis M.D.
drgeroulis.fromyourdoctor.com
NEUROLOGY
NAME:_________________________________________________________________
AGE: _________________________________________________________________
Today's Date: ___________________________________________________________
Social Sec #______________________________________________________________
HOME Phone:___________________________________________________________
WORK Phone:__________________________________________________________
PHARMACY Phone: _____________________________________________________
Sex:__M__F__Birthdate:____/____/__________Single___Married___Widowed___Separated___Divorced
Patient Employed by:_____________________________________________________________________
Business Address:
Street__________________________City________________State_______________Zip______________
Primary Insurance: Card Holder Name: ________________________________
Secondary Insurance: Card Holder Name: ______________________________
Do we have your permission to ask your doctor for records related to the reason for this appointment?
Assignment of Benefits-Release of Medical Records: I hereby authorize the release of any information
needed by my carrier to process the claim. I understand that I am financially responsible for all charges;
these may include, but are not limited to, deductibles, co-pays, and “non-covered services”.
YES _______
Signature______________________________ Date___________
Please answer the following questions and bring the answers to your appointment. There
is room at the end of each section for additional comments. Please give necessary details
for "yes" answers.
1
HEADACHE QUESTIONNAIRE
Present Illness
My headaches started on:
I get headaches about every: (circle)
day week
month
three-months
year
My headaches last: seconds - minutes - hours - days
(circle)
Describe the head pain you experience (circle one or several)
throbbing
pulsating
pounding
constant
tight
squeezing
pressure
sharp
grinding
vise-like
hat-band
tender
other:
Please circle the numbers that represent the minimum, maximum and average severity
of your pain: (circle)
Mild 1 2 3 4 5 6 7 8 9 10 Severe
What time of day do you usually get headaches? (circle)
Morning
Afternoon
Night
There is no pattern
Are your headaches worse with changes in position (such as lying down or sitting,
standing etc.)? (circle)
Yes
No
Are your headaches associated with: (circle)
menstrual cycle
allergy/sinus problems
none of the above
cold/flu
changes in weather
Do your headaches waken you in the middle of the night? (circle)
Yes
No
Do you ever waken with your jaws clenched together? (circle)
Yes
No
Do you wake up in the morning with headaches?
2
Yes
No
Do you snore?
Yes
No
My headaches are located: (mark location, one or several)
My headaches start here: (if applicable circle area headaches tend to start)
My headaches radiate: (if applicable circle where headaches start and end)
3
HEADACHE QUESTIONNAIRE
Associations
Headache is accompanied by (circle all that apply)
Diarrhea
dizziness
drooping eye lid
flushing on one side of the face
light sensitivity
facial tenderness
loss of consciousness
nausea or vomiting
neck stiffness
noise sensitivity
red, tearing eye
runny nose/congestion
swelling of ankles
speech disturbance
weakness in face/arm/leg
abdominal pain
neck tightness
jaw pain or jaw clenching
visual disturbances –
black spots
heat waves
flashing lights
jagged lines
other:
4
fever
numbness in face/arm/leg
neck pain
HEADACHE QUESTIONNAIRE
Is your head pain triggered by any of the following?: (circle all that apply)
Alcoholic beverages
Seasons
Bending over
Swallowing
Blood Pressure
Sleep or lack of sleep
Bright Lights
Time of day
Colds
Sex
Coughing
Salt
Depression, anxiety, nerves, or stress
Other:
Exertion, exercise
Fatigue
Foods (such as cheese or chocolate)
Heat, hot showers
Head movement
Loud noises
Menstrual periods
Meals, or missing meals
Monosodium glutamate (MSG)
Odors
5
HEADACHE QUESTIONNAIRE
Is your head pain relieved by any of the following?: (circle all that apply)
Cold compresses
Eating
Heat
Massage
Medication (which ones?)
Moving around
Relaxation
Sleep
Vomiting
Other:
6
HEADACHE QUESTIONNAIRE
Life Style
Habits
How many alcoholic drinks per week ?
_______
none
No
Yes
None
>4
No
Yes
Do you smoke cigarettes, cigars or pipes ?
How many caffeinated drinks per day?
Do you have regular sleep/wake patterns ?
Do you salt your food?
None
moderate
lots
Are you currently involved in litigation with
respect to any medical problems ?
No
Yes
Are you usually highly stressed?
No
Yes
Do you usually eat 3 meals/day?
No
Yes
Injuries (Circle, date)
Head
Neck (for example whiplash)
Dental work preceding onset of headache ?
Exposures or Infections (Circle, date)
Carbon Monoxide (car or house)
Tuberculosis or Cysticercosis ?
History of meningitis?
7
HEADACHE QUESTIONNAIRE
MEDICATIONS
What are your current medications, include hormones, birth control pills, vitamins, etc.
(Name and amount/day)?
1
2
3
4
5
6
7
8
9
10
11
12
Have you ever taken any of the following medicines for headache : (circle)
Alleve
Amerge
Amitriptyline
Botox
Bufferin Cafergot
Calan
Datril
Dapro
Dilantin
Depakote
Duradrin
Effexor
Empirin
Fiorinal
Gabatril
Ibuprofen
Lithium
Magnesium
Nortriptyline
Relpax
Topamax
Nuprin
Robaxin
Tylenol
Anacin Antihistamines Aspirin Axert
Oxygen
Ergomar
Ergostat
Maxalt
Paxil
Midrin
Inderal
Pamelor Percodan
Sinutab
Verapamil
Soma
Vivactyl
Esgic
Motrin
Bellergal
Darvon/Darvocet
Demerol
Imitrex (or related drug)
Sertraline
Venlafaxine
Cyproheptadine
Decongestants
Elavil
Methadone
Sansert
Codeine
Axotal
Depakote
Fentanyl patch
Indocin
Naprosyn
Percogesic
Feverfew
Indomethacin
Norflex
Periactin
Stadol Nasal Spray
Vicodin
DHE
Norgesic
Phrenilin
Sumatriptin
Wellbutrin Zoloft
Zomig
Other:_________________________________________________________________________________
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8
HEADACHE QUESTIONNAIRE
Past Medical History, Review of Systems
My health has been affected by: (circle, date)
General Health
Troubles
Psychological
Problems
Heart problems
Treatment by a psychiatrist or counselor
High cholesterol
Depression or unusual amounts of stress
High or low blood pressure
Panic Attacks
Diabetes
Pain
Palpitations (abnormal or fast
beating) of the heart
Pain in back of jaw (TMJ)
Migraine or other headaches
Cancer
What type
Low Back or Neck Pain
15 lb or more weight
loss
Systemic Diseases
AIDS
Metabolic
Arthritis
Kidney problems
Blood diseases, anemia
Dialysis
Liver disease
Fevers or swollen glands
Low sugar
(hypoglycemia)
Skin diseases
9
HEADACHE QUESTIONNAIRE
Thyroid disorders
Lupus
Syphilis or venereal disease
Mononucleosis (Epstein Barr)
Lyme disease
Meningitis
Tuberculosis (TB)
Eye Problems (circle)
Crossed eyes, lazy eye
Poor vision in one eye (amblyopia)
Neurological Problems (circle)
Bladder problems
Tremor or incoordination
Loss of consciousness (faints or
seizures)
Pins and needles, numbness (where)
Muscle weakness (where)
Problems with sexual function
Trouble speaking
Surgery: (circle)
Appendix
Breast
Ear
Gall Bladder
Stomach
Tonsils
Cataract
Carotid
Hysterectomy
C-Section
Prostate
Other: _________________________
10
Sinus
HEADACHE QUESTIONNAIRE
Family History
Are there any family members with (circle):
Headaches just like mine
Diabetes
Stroke
Heart disease or high blood pressure
Migraine headaches
Other diseases that run in the family (list)
11
HEADACHE QUESTIONNAIRE
PREVIOUS STUDIES
11. Have you had any of these tests or procedures ? (circle, date if done, and please note
result if known)
OTHER SPECIALTY VISITS
Eye Doctor
Dentist
Chiropractor
NEUROLOGICAL TESTS
Carotid Doppler
Lumbar puncture (spinal fluid examination)
EEG (Brain Wave test for seizures)
GENERAL MEDICAL TESTS
Recent general medical checkup?
Recent general blood tests (Glucose, blood count)
Heart testing (EKG, Stress test, Holter Monitor)
X-RAYS
Cerebral Angiogram
MRI, MRA and/or CT scan of the head
Sinus X-rays or CT
Neck X-rays, CT or MRI
Chest X-ray
Thank You!
12