The Headache Healer’s Handbook. Jan Mundo

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       caffeine

       chocolate

       citrus fruits

       dairy products

       fatty foods

       food sensitivity (list): ___________________________

       hot dogs

       irregular eating

       lack of caffeine

       lack of water

       low blood sugar

       luncheon meats

       MSG

       nitrates, nitrites

       nuts

       pickled foods

       preservatives, chemical

       additives

       skipping meals

       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

       chiropractor

       craniosacral therapist

       dentist

       ENT (ear, nose, and throat doctor; or otolaryngologist)

       general practitioner

       healer

       herbalist

       homeopath

       massage therapist

       naturopath

       neurologist

       nurse practitioner

       OB/GYN

       occupational therapist

       ophthalmologist

       optometrist

       orthodontist

       osteopath

       pain specialist