Headache Symptom Tracker Form
Use this form to record and track your headache patterns and related symptoms for better awareness and management.
Date of Headache
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Onset
*
Hour Minutes
AM
PM
AM/PM Option
Duration (in hours)
*
Headache Intensity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Location of Pain
*
Forehead
Temple(s)
Behind Eyes
Back of Head
One Side Only
Other
Associated Symptoms
Nausea
Vomiting
Sensitivity to Light
Sensitivity to Sound
Blurred Vision
Other
Possible Triggers
Stress
Lack of Sleep
Certain Foods
Weather Changes
Hormonal Changes
Other
Medication Taken
None
Over-the-counter Pain Reliever
Prescription Medication
Other
Relief Measures Tried
Rest/Sleep
Hydration
Cold Compress
Dark Room
Other
Frequency of Headaches (in the last month)
*
Please Select
First occurrence
1-2 times
3-5 times
6-10 times
More than 10 times
Additional Notes
Submit Entry
Should be Empty: