IMPERIAL CRS

2 Headache Details This section should be completed for every headache experienced. If two or more headaches occur on one day, they should each be entered on separate lines. Below is an example of the details for the headaches entered in the headache log on the previous page. Note that this patient had a headache that lasted two days, from 07/07/2020 to 07/08/2020: Headache number 1 START date and time for this headache: Date / / Time : AM PM END date and time for this headache: Date / / Time : AM PM What was the intensity of pain for this headache? (indicate 0-10 using scale) Did your pain pulsate, pound, or throb? Was your pain mostly on one side or both sides of your head? What was maximum severity of nausea for this headache? What was maximum severity of vomiting for this headache? What was maximum severity of sensitivity to light for this headache? What was maximum severity of sensitivity to sound for this headache? Was this headache worsened by activity or cause you to avoid activity? Did you experience aura with this headache? If yes, did the aura symptom spread gradually over several minutes? If yes, how long did the aura last? Did you take any non-study medications to treat this headache? 6 Yes No Right side Left side Both sides None Mild Moderate Severe None Mild Moderate Severe None Mild Moderate Severe None Mild Moderate Severe Yes No Yes No Yes No mins Yes No Medication(s) taken Date taken Times(s) taken a NSAID Acetaminophen Combination Analgesic Triptan Ergotamine / / 9:15 AM; 3:00 PM b NSAID Acetaminophen Combination Analgesic Triptan Ergotamine / / c NSAID Acetaminophen Combination Analgesic Triptan Ergotamine / / Headache number 2 START date and time for this headache: Date / / Time : AM PM END date and time for this headache: Date 07 10 2020 Time : AM PM What was the intensity of pain for this headache? (indicate 0-10 using scale) Did your pain pulsate, pound, or throb? Was your pain mostly on one side or both sides of your head? What was maximum severity of nausea for this headache? What was maximum severity of vomiting for this headache? What was maximum severity of sensitivity to light for this headache? What was maximum severity of sensitivity to sound for this headache? Was this headache worsened by activity or cause you to avoid activity? Did you experience aura with this headache? If yes, did the aura symptom spread gradually over several minutes? If yes, how long did the aura last? Did you take any non-study medications to treat this headache? 4 Yes No Right side Left side Both sides None Mild Moderate Severe None Mild Moderate Severe None Mild Moderate Severe None Mild Moderate Severe Yes No Yes No Yes No mins Yes No Medication(s) taken Date taken Times(s) taken a NSAID Acetaminophen Combination Analgesic Triptan Ergotamine / / 5:15 PM b NSAID Acetaminophen Combination Analgesic Triptan Ergotamine / / 8:30 pm c NSAID Acetaminophen Combination Analgesic Triptan Ergotamine / / 07 07 2020 07 08 2020 8 30 10 45 X X X X X X X X X X X 07 07 2020 X 07 10 2020 07 10 2020 X X X X X X X X X X X 07 10 2020 4 30 9 30 X 30 X X

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