Headache and medicine-day record
For discussion with a clinician. No diagnosis, safe-use allowance, taper or dosing recommendation. Do not delay urgent care to complete it.
Period and current plan
Month/year: ____ Clinician and next review: ____ Current prescribed instructions (copy accurately): ____
Daily record
Date | Headache today? | Start/end or approximate duration | Effect on activities | Exact medicine/product and quantity | Time used | Response/unwanted effects ____ | ____ | ____ | ____ | ____ | ____ | ____ ____ | ____ | ____ | ____ | ____ | ____ | ____ ____ | ____ | ____ | ____ | ____ | ____ | ____
Calendar counts for discussion
Headache dates: ____ Dates using product A: ____ Dates using product B: ____ Dates using any acute medicine (count an overlapping date once): ____ Do not add doses as calendar days. Keep dose information separately. These counts do not diagnose medication-overuse headache.
Questions for the prescriber
Which products are changing? ____ Exactly how, according to the prescriber? ____ What is the plan for an attack during the change? ____ What requires urgent help or a call? ____ When and how will the plan be reviewed? ____
Original organizational template, not a medical test. All free decision records · Related reading paths