Subjective/History Elements
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Headache
Onset [text size="3"] [select value="hour(s)|day(s)|week(s)"] ago.
Onset while: [text default="ACTIVITY" size="30"]
Location: [text size="30"]
Radiation: [text size="30"]
Severity now (0-10): [select value="1|2|3|4|5|6|7|8|9|10"]/10
Severity at worst: [select value="1|2|3|4|5|6|7|8|9|10"]/10
Characterized as [checkbox value="sharp|dull|throbbing|OTHER-"] [text size="30"].
Headache progression: [select value="getting better|GETTING WORSE|the same"]

Pain modifiers:
Relieved with [text size="30"].
Worse with [text size="30"].
[select value="no|YES"] <-- worse with bright lights.
[select value="no|YES"] <-- worse with loud noises.

Associated Symptoms:
[select value="no|YES"] <-- nausea/vomiting
[select value="no|YES"] <-- preceding aura before the headache (e.g. vision change, smell, other symptom prodrome)
[select value="no|YES"] <-- blurred vision
[select value="no|YES"] <-- fever
[select value="no|YES"] <-- sinus pressure or nasal drainage
[select value="no|YES"] <-- arm/leg weakness
[textarea memo="additional details"]

Pertinent PMH
[select value="no|YES"] <-- Migraine Headache
[select value="no|YES"] <-- frequent Sinusitis
[select value="no|YES"] <-- Glaucoma
[select value="no|YES"] <-- Head Trauma
[select value="no|YES"] <-- Serious CNS risks (e.g. active cancer, immunosuppression, HIV)
[select value="no|YES"] <-- Exposures (e.g. Tick bites, carbon monoxide)

[select value="no|YES"] <-- Family history of cerebral aneurysm or stroke

[comment memo="modified from original reference: contributed by Dr. Scott Moses, creator/author of the Family Practice Notebook, http://www.fpnotebook.com"]

[comment memo="For use in CRDAMC FM Clinic"]
Headache
Onset ago.
Onset while:
Location:
Radiation:
Severity now (0-10): /10
Severity at worst: /10
Characterized as .
Headache progression:

Pain modifiers:
Relieved with .
Worse with .
<-- worse with bright lights.
<-- worse with loud noises.

Associated Symptoms:
<-- nausea/vomiting
<-- preceding aura before the headache (e.g. vision change, smell, other symptom prodrome)
<-- blurred vision
<-- fever
<-- sinus pressure or nasal drainage
<-- arm/leg weakness
additional details

Pertinent PMH
<-- Migraine Headache
<-- frequent Sinusitis
<-- Glaucoma
<-- Head Trauma
<-- Serious CNS risks (e.g. active cancer, immunosuppression, HIV)
<-- Exposures (e.g. Tick bites, carbon monoxide)

<-- Family history of cerebral aneurysm or stroke

modified from original reference: contributed by Dr. Scott Moses, creator/author of the Family Practice Notebook, http://www.fpnotebook.com

For use in CRDAMC FM Clinic
Result - Copy and paste this output: