sugar
wheat gluten
wine, red
wine, white
Hormonal
birth
birth control (pills, IUD, patch)
hormone replacement therapy
menarche (onset of first period)
menopause
menstruation
ovulation
perimenopause
pregnancy
Environmental
air pollution
bright light
chemical sensitivity
cigarette smoke
cold
damp weather
dim light
dry air
fluorescent lighting
fumes
heat
high altitude
hot, dry winds
humidity
loud noise
low barometric pressure
perfume, scents
stormy weather
strong odors
sun overexposure
weather changes
Lifestyle
cigarette smoking
disrupted sleep
excessive sleep
fatigue
insufficient sleep
let-down headache
motion
recreational drugs
routine change
stress
travel
Medication
analgesic, simple (overuse)
analgesic, combination (overuse)
antiasthma drugs
antidepressants
antiseizure drugs
blood pressure drugs
blood vessel dilators
diuretics
“drug cocktail” (combining several medications)
ergotamine overuse
opioid overuse
triptan overuse
Physical
allergy
cell phone (texting), electronic device use
computer overuse
exercise
exertion from sex
exertion from sports
eyestrain
flu, cold, or virus
head trauma
neck, shoulder, back tension
poor posture
sedentary lifestyle
sinusitis, rhinitis
anything else (in any category): _________________________________
21. How many hours of quality sleep do you get per night? _____
22. How much of the following do you drink daily?
water (# oz.): _____
coffee (# oz.): _____
tea (# oz.): _____
espresso (# shots): _____
cola (# oz.): _____
soda (# oz.): _____
23. List the approximate times of day you eat:
breakfast: _____ AM
snack: _____ AM
lunch: _____ PM
snack: _____ PM
dinner: _____ PM
snack: _____ PM
24. List what you typically eat for each meal and snack:
Breakfast: ______________________________________________
Morning snack: __________________________________________
Lunch: ________________________________________________
Afternoon snack: _________________________________________
Dinner: ________________________________________________
Evening snack: ___________________________________________
25. Do you exercise? yes _____ no _____
If yes, how many times per week? _____
How many minutes per session? _____
Type(s) of exercise: ____________________________________
26. Circle the types of practitioner you have seen for your headaches:
acupuncturist/DOM
allergist
bodyworker
