Headache Symptom Survey

Instructions: Please rate the severity of each symptom on a scale of 1-10 (1 = very mild, 10 = very severe). Write your rating in the space provided next to each item

Headache Characteristics

1. Does your headache tend to begin or worsen during or after prolonged reading or screen use?

2. Do they start behind the eyes or around the brow/forehead areas?

3. Are your headaches accompanied by eyestrain or the sensation of needing to rub your eyes?

4. Does your headache or symptoms improve when you close her eyes?

5. Do you headaches occur more frequently in visually stimulating environments (e.g., grocery stores, crowds, scrolling on your phone)?

6. Does driving tend to provoke or worsen your symptoms?

Visual Function Symptoms​​​​​​​

7. Do words move on a page or screen, blur, double, or come in and out of focus?

8. Do you lose your place when reading or skip lines?

9. Do you feel nauseated, disoriented or dizzy when using your vision for extended periods of time?

10. Do you feel like your eyes are working too hard to focus, especially when doing near tasks?

11. Do you experience double vision or shadows when fatigued?

12. Do your eyes feel tired, heavy, or sore at the end of the day?

13. Do you have a Head Tilt?

14. Do you have difficulty shifting focus from near to far?

15. Do you feel overwhelmed or anxious in busy areas?

16. Does running or working out make your headaches worse?

17. Do you have dull pain and tenderness around the eyes and cheekbones after reading or doing near tasks?

Other symptoms you'd like to share:

Are symptoms worse at certain times of the day?

Currently receiving vestibular therapy?

Thank you for completing this survey. This information helps us better understand your visual and vestibular needs.

Patient Name:

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Date: