The Headache Healer’s Handbook. Jan Mundo

physical therapist

       primary care provider

       psychiatrist

       psychologist

       registered dietitian, nutritionist

       Reiki or energy-work practitioner

       social worker

       other (describe): ___________________________________________

      27. List headache medications taken during the past five years (prescription and over-the-counter):

       MEDICATION: __________________________________________________

       Dose unit (tablet/tsp/mg/ml): ______ Frequency (per day/week/month): ______

       Dates taken: ____ to ____ # of years taken: ____

       Still use? yes no

       Effective? yes no

       Side effects? yes no

       List side effects: ______________________________________________________

       Reason(s) stopped or still using: ________________________________________

       MEDICATION: __________________________________________________

       Dose unit (tablet/tsp/mg/ml): ______ Frequency (per day/week/month): ______

       Dates taken: ____ to ____ # of years taken: ____

       Still use? yes no

       Effective? yes no

       Side effects? yes no

       List side effects: ______________________________________________________

       Reason(s) stopped or still using: ________________________________________

       MEDICATION: __________________________________________________

       Dose unit (tablet/tsp/mg/ml): ______ Frequency (per day/week/month): ______

       Dates taken: ____ to ____ # of years taken: ____

       Still use? yes no

       Effective? yes no

       Side effects? yes no

       List side effects: ______________________________________________________

       Reason(s) stopped or still using: ________________________________________

      28. List other medications taken regularly over the past five years (for example, medication for birth control, hormone replacement, thyroid condition, blood pressure, heart condition, chronic pain, depression, sleep issues, anxiety, or sinus condition):

       MEDICATION: __________________________________________________

       Dose unit (tablet/tsp/mg/ml): ______ Frequency (per day/week/month): ______

       Dates taken: ____ to ____ # of years taken: ____

       Still use? yes no

       Effective? yes no

       Side effects? yes no

       List side effects: ______________________________________________________

       Reason(s) stopped or still using: ________________________________________

       MEDICATION: __________________________________________________

       Dose unit (tablet/tsp/mg/ml): ______ Frequency (per day/week/month): ______

       Dates taken: ____ to ____ # of years taken: ____

       Still use?