Children's Headache Tracker Form
Use this form to record your child's headache patterns and possible triggers for better tracking and understanding.
Child's Name
*
First Name
Last Name
Date and Time of Headache
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
How long did the headache last? (in minutes or hours)
How would you rate the headache's intensity?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Where was the headache located?
Forehead
Back of Head
One Side
All Over
Other
Possible triggers (select all that apply)
Skipped meal
Stress or anxiety
Lack of sleep
Screen time
Dehydration
Weather changes
Other
Were there any other symptoms?
Nausea
Sensitivity to light
Sensitivity to sound
Dizziness
Other
What actions were taken to help the headache?
Rested
Drank water
Used cold compress
Reduced screen time
Other
Notes (optional)
Submit Entry
Should be Empty: