Headaches Monitoring Form
Use this form to keep track of your daily headaches as well as doses of up to three different medications used to control them. Leave the boxes empty for headache-free days. The headaches severity evaluation is based on your capacity to perform activities:
| Severe headache: No activity is possible | Moderate headache: Restricted activities | Mild headache: Normal activity |
| Month: | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Menstruations (check) | |||||||||||||||||||||||||||||||
| Severe headache | |||||||||||||||||||||||||||||||
| Moderate headache | |||||||||||||||||||||||||||||||
| Mild headache | |||||||||||||||||||||||||||||||
| 1. | |||||||||||||||||||||||||||||||
| 2. | |||||||||||||||||||||||||||||||
| 3. |
Concerning the last month (to do at the end of the month)
Fill in the next form considering the headaches you suffered.
| With... | Always | Often | Occasionally | Never |
|---|---|---|---|---|
| ☐ | ☐ | ☐ | ☐ |
| ☐ | ☐ | ☐ | ☐ |
| ☐ | ☐ | ☐ | ☐ |
| ☐ | ☐ | ☐ | ☐ |
| Located on one side of the head | ☐ | ☐ | ☐ | ☐ |
| Exacerbated by activity | ☐ | ☐ | ☐ | ☐ |
| Suspected dietary triggers: | ||||
| Notes: | ||||
Fill in the next form considering the drugs you took for your headaches.
| Drugs | 1. | 2. | 3. |
|---|---|---|---|
| No relief | ☐ | ☐ | ☐ |
| Low relief | ☐ | ☐ | ☐ |
| Medium relief | ☐ | ☐ | ☐ |
| Full relief | ☐ | ☐ | ☐ |
| No side effect | ☐ | ☐ | ☐ |
| Side effects (name them) |
© Copyright Vigilance Santé
The patient information leaflets are provided by Vigilance Santé Inc. This content is for information purposes only and does not in any manner whatsoever replace the opinion or advice of your health care professional. Always consult a health care professional before making a decision about your medication or treatment.