A Daily Tracking Tool for Headache Patients
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Name: _________________
Date Range: //___ to //___
0 = No Pain
1-3 = Mild Pain
4-6 = Moderate Pain
7-10 = Severe Pain
Date: //___
Time Headache Started: _____
Pain Level (0-10): _____
Location of Pain:
Associated Symptoms:
Potential Triggers:
Medications Taken:
Name: _____________ Dose: _____ Time: _____
Relief achieved? Yes [ ] No [ ] Partial [ ]
Activities Affected:
Total headache days: _____
Severe headache days: _____
Most common triggers: _____________
Most effective treatments: _____________
Bring this chart to your next neurology appointment
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