Headache Evaluation
Our Headache Evaluation is the most comprehensive we have seen and it writes a report that can be utilized with little or no editing. In addition to organizing the evaluation data collected into a clear and precise report the program offers the top three “most probable diagnoses” given the symptoms provided. Ask of the patient specifically, or learn from your interview, the information required to answer as many of the questions in the form as possible. You can accomplish this while online (entering each response as you acquire the information) or you can print the form so as to facilitate your gathering of the information off-line. In either case, once you have the data, enter it into the form on-line and submit it. Within seconds to a minute you will receive a completed report, formatted and displayed as a printable webpage on your screen.
Example Headache Evaluation computer generated report:
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Headache Evaluation Report
October 17, 2009
Name : Jane Doe
Sex : female
Date of Birth : March/15/1980
Jane Doe is a 29 year old female who has experienced problems with headaches since she was 15 years old. Since that time the frequency of the headaches has increased and the severity of the headaches has increased. There is a history of headaches in this patient’s family.
The headaches do appear associated in time with this patient’s menstrual cycle. She does take birth control pills.
The patient reports that there are significant life/work stresses affecting her at this time. She indicates that she does not have an eating disorder. She thinks that she is both anxious and depressed.
The patient indicates that she has received treatment for her headaches in the past. She indicates that the following treatments have been effective:
relaxation therapy
massage
medication
time off work
This patient reports that her headaches occur about 1 to 3 times per week. Over the time period in which headaches have been a problem, there has been no observable time pattern to their occurance. The pain is described as usually coming on gradually, being moderate in degree and being such that it comes and goes. Typically, the headaches will last up to 24 hours from when the patient first notices them until they go away. She reports that her headaches tend to start during the morning after she has already gotten up from sleep. She reports that the headaches seem worse during the evenings. She indicates that the headaches seem to be made worse by:
drinking alcohol
smoking
excitement or crisis
after missing a meal or while dieting
She reports that the headaches seem to get better with rest.
The patient indicates that the headaches usually start following a stressful event.
When the headache first appears the pain is usually unilateral, more anterior, focused in one spot, around one eye and above the eyes. Later after the headache is fully developed the pain is usually bilateral, more anterior, more general in location and above the eyes. The patient reports that there is a tenderness associated with the headaches located in the neck area. The patient reports that the following medications have been of help in the past:
Analgesics
Narcotics
The patient checked the following attributes as applying to her headache:
throbbing
a pressure inside the head
worse when straining like to go to the bathroom
worse while standing up
aching neck, shoulders or back
trouble falling asleep
tenseness
anxiety
irritability
Diagnostic Considerations:
The pattern of signs and symptoms endorsed by this patient appear most like the following headache types ranked in order of probability:
Tension Related Chronic Mild Migraine
Occipital-Orbital Migraine
Tension Headache
Note: This program and report is intended to serve as an aid to a competent and licensed clinician who is solely and totally responsible for evaluating the patient and making a diagnosis based upon that clinician’s expertise and opinion.
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