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checklist Headache

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Opening the consultation

  • Wash your hands and Ask the patient to sit, and collect token.
  • Introduce yourself to the patient including your name and role
  • Confirm the patient's name and date of birth - CR number.
  • Explain that you'd like to take a history from the patient
  • Gain consent to proceed with taking a history a

Presenting complaint

  • Use open questioning to explore the patient's presenting complaint

History of presenting complaint

  • Site: ask where the headache is
  • Onset: clarify when the headache first started and if the onset was sudden or gradual
  • Character: ask the patient to describe how the headache feels
  • Radiation: ask if the headache moves anywhere else
  • Associated symptoms: ask if there are any other associated symptoms
  • Time course: ask how the headache has changed over time
  • Exacerbating or relieving factors: ask if anything makes the headache worse or better
  • Severity: ask how severe the headache is on a scale of 0-10
  • Screen for other key symptoms including red flag features
  • Explore the patient's ideas, concerns and expectations
  • Summarise the patient's presenting complaint.

Systemic enquiry

  • Screen for relevant symptoms in other body systems

Past medical and surgical history

  • Ask if the patient has any medical conditions
  • Ask if the patient has had any relevant surgical procedures
  • Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the

substance Drug history

  • Ask f the patient is currently taking any prescribed medications or over-the counter remedies
  • Ask about medications which are associated with medication-overuse headaches including frequency of use

Family history

24 Ask the patient if there is any family history of headaches, cancer, bleeds on the brain, clotting disorders or bleeding disorders Social history 25 Explore the patient's general social context 26 Take a smoking history 27 Take an alcohol history 28 Ask about recreational drug use Gather details a tho patient's occupatoin

Closing the consultation 30 Summarise the salient points of the history back to the patient and ask if they feel anything has been missed 31 Thank the patient for their time 32 Dispose of gloves If used .

Key communication skills 33 Active listening 34 Summarising 35 Signposting