Headache Journal

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Headaches and Trigger Points
Headache Pain Treatment Publications

Symptom                                   |  Y  |  N  |  Sometimes   |  Comments/Notes
The Pain occurs in:
Right Eye
Left Eye
Both Eyes
Forehead
Right Temple
Left Temple
Both Temples
Temple and Jaw
Back of Head and Neck
Front of Head and Teeth
Other
Vision:
My Vision Blurs in Left Eye
My Vision Blurs in Right Eye
My Vision Blurs in Both Eyes
I Lose Vision in One/Both Eyes
My Headaches Occur
1- 3 Times Weekly
4-6 Times Weekly
Before my Menstrual Cycle
During my Menstrual Cycle
I Become Sensitive to:
Light
Sound
Odors
All of the above
I Experience:
Nausea
Vomiting
Sinus Congestion
Sinus Draining
Tooth Pain
Dizziness
Diarrhea
Constipation
Confusion
Depression
Anxiety
Foods Consumed before Headache:
Food Containing Wheat.
Sweets/Beverages Containing Sugar.
Dairy
Chocolate
Wine/Other Alcohol
Beer
Coffee/Tea
Soda/Diet Soda
I have a sleep disorder
I have recently had my
blood pressure checked
I have been tested for TMJ
I am currently taking
medication for my headaches
I am currently taking medications
for another condition
I Sleep (enter average #
of hours you sleep)

 

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