FMS
Community Index Page
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) |