Contact Dr Raeburn ForbesAsk a Question about Headache Please note that all fields followed by an asterisk must be filled in.First Name* Last NameE-mail Address*Please enter your email, or I will be unable to answer. 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If you have time, consider filling in the other 16 short questions - although they are really there to prompt you to give as much detail as you can in your question. If you are requesting an appointment please remember your surname and a contact telephone number.1. How many years have you had headaches?---Select---123456789101112131415 or more2. Please indicate your approximate age---Select---<12 years (I do not treat children, so this form cannot be used)12-18 years18-30 years30-50 years50-70 years70-90 yearsOlder than 90 years3. Is the person with headaches male or female?MaleFemaleHow many days a month do you get headaches?Every day - there's always some sort of painMost days - its at least 15 days per monthSome days - probably 1 or 2 per weekA few - probably 1 or 2 per monthNone - or my enquiry is not about headaches4. Which side of the head is sore?Always RIGHT sidedAlways LEFT sidedMostly RIGHT sidedMostly LEFT sidedBOTH SidesSWAPS sides but only one at a time5. Which part of your head is sore?(If more than one, enter worst location)Back of HeadSide of headTop of HeadForeheadIn the Eye or around the EyeEar/side of headFace/cheek/noseJawIt can move from place to placeIt's the whole headIt's hard to say, it's just sore6. Do any of the following happen alongside your headaches? I prefer to lie down I feel sick or nauseated I prefer the dark or avoid light I prefer silence or avoid noise I avoid smells such as perfume or cooked food My eye streams water a lot My nose feels blocked up I pace the floor feeling very agitated None of the above - it's just sore7. Do any of the following descriptions apply to the pains you get in your head? Sharp Throbbing Pressure Splitting Shooting Stabbing, like a dart or knife Aching Pounding Difficult to describe - just severe8. When the pain is worst, what is the pain like?---Select---SharpThrobbingPressureSplittingShootingStabbing, like a dart or knifeAchingPoundingDifficult to describe - just severeLike my head is going to burst or explodeLike a weight on my headTightness around the head or on the head9. If you are pain free between headaches - how long does an EPISODE of headache last?---Select---A few secondsSeconds, up to 2 minutes2-5 minutes5-15 minutes15 minutes to 3 hours3-24 hoursUp to 3 days3-7 daysMore than 7 days, but will still always go awayDifficult to say - it varies so much10. If you have EPISODES of headache, how many episodes of headache could you get in one day? 1 2 3 4 5 6 7 8 Dozens - more than I can count11. In the last 3 months, what is the longest time you have been pain-free?---Select---I am never pain freeMinutesHoursA daySeveral Days, but less than a weekA week2 weeks3 weeks4 weeksMore than 4 weeks12. In the last 3 months...I have had pain in my head every single dayI have pain in my head most daysI have had one or two headache episode each week, but have some pain free daysI have had no more than one headache per week, with many pain free daysI only get headaches that waken me from sleep, they never start in daytime13. Do any of the following movements or actions bring on a headache? Coughing Physical exercise like weight-lifting/running/cycling Stooping down to lift something from the floor Laughing Sleep14. Have you ever had any of these Blood Tests for headache Blood Count (to exclude anaemia) Thyroid Function Tests ESR (sedimentation rate) C-Reactive Protein Don't Know15. Have you had any of these tests for your headaches? CT Brain Scan CT Paranasal Sinuses CT Cerebral Venogram MRI Brain MRI Brain with Gadolinium MR Myelogram Cerebral Angiogram Lumbar Puncture Procedure Visual Field Test16. Can you tell me the results of any of these tests?Please leave any other comment or information here. Remember to leave your contact number if you want a private appointment.PhoneThis field is for validation purposes and should be left unchanged. References:Peters M et al Quality in the provision of headache care. 1: systematic review of the literature and commentary J Headache Pain. 2012; 13(6): 437–447.Peters M et al Quality in the provision of headache care. 2: defining quality and its indicators. J Headache Pain 2012 Aug;13(6):449-57.