APPOINTMENT PREPARATION
Headache Visit Record
Date range: _____________________ to _____________________
Clinic PHQ-9 total (optional): ________ ยท Keep separate; bring the original form.
Write dates below. Count calendar days, not attacks. ? = unknown, not headache-free.
| Date | Headache? | Observation |
|---|---|---|
| Day 1 | Yes / No / ? | |
| Day 2 | Yes / No / ? | |
| Day 3 | Yes / No / ? | |
| Day 4 | Yes / No / ? | |
| Day 5 | Yes / No / ? | |
| Day 6 | Yes / No / ? | |
| Day 7 | Yes / No / ? | |
| Day 8 | Yes / No / ? | |
| Day 9 | Yes / No / ? | |
| Day 10 | Yes / No / ? | |
| Day 11 | Yes / No / ? | |
| Day 12 | Yes / No / ? | |
| Day 13 | Yes / No / ? | |
| Day 14 | Yes / No / ? |
Bring both records to the appointment
Headache days: _____ of _____ observed days. Unknown or missing dates: _____.
Bring the full clinic questionnaire, all individual responses, medicines list and any longer diary.
A record, not a diagnosis. This sheet does not explain causes, assess depression or choose treatment. Seek emergency care for sudden extremely painful headache, new weakness or confusion, a seizure, loss of vision, fever with stiff neck, or headache after a head injury. Seek prompt support for suicidal or self-harm thoughts; use emergency care if you cannot stay safe. Do not wait to finish a diary.