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Headache Disability IndexJared Larsen2020-09-22T17:22:04+00:00

Headache Disability Survey

This questionnaire has been designed to give us information as to how your headaches are affecting your ability to manage in everyday life.

Step 1 of 32

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  • Name
  • Please select your case manager
  • Please select the most accurate response regarding your headaches
  • Please select the most accurate response regarding your headaches

  • The purpose of the scale is to identify difficulties that you may be experiencing because of your headache. Please select โ€œYESโ€, โ€œSOMETIMESโ€, or โ€œNOโ€ to each item. Answer each question as it pertains to your headache only.
  • Because of my headaches I feel disabled.
  • Because of my headaches I feel restricted in performing my routine daily activities.
  • No one understands the effect my headaches have on my life.
  • I restrict my recreational activities (eg, sports, hobbies) because of my headaches.
  • My headaches make me angry.
  • Sometimes I feel that I am going to lose control because of my headaches.
  • Because of my headaches I am less likely to socialize.
  • My spouse (significant other), or family and friends have no idea what I am going through because of my headaches.
  • My headaches are so bad that I feel that I am going to go insane.
  • My outlook on the world is affected by my headaches.
  • I am afraid to go outside when I feel that a headaches is starting.
  • I feel desperate because of my headaches.
  • I am concerned that I am paying penalties at work or at home because of my headaches.
  • My headaches place stress on my relationships with family or friends.
  • I avoid being around people when I have a headache.
  • I believe my headaches are making it difficult for me to achieve my goals in life.
  • I am unable to think clearly because of my headaches.
  • I get tense (eg, muscle tension) because of my headaches.
  • I do not enjoy social gatherings because of my headaches.
  • I feel irritable because of my headaches.
  • I avoid traveling because of my headaches.
  • My headaches make me feel confused.
  • My headaches make me feel frustrated.
  • I find it difficult to read because of my headaches.
  • I find it difficult to focus my attention away from my headaches and on other things.
  • Please describe how your headaches affect your daily life activities
  • Please select any areas where your life has been affected by your headaches
  • Are you taking medication for your headaches?
  • Medication Name
  • How Long have you taken this medication?
  • How often do you take this medication?
    Less than once per weekOnce per week1-2 days per weekMost days per weekDailyMultiple times daily
  • Are you taking additional medication for your headaches?
  • Medication Name
  • How Long have you taken this medication?
  • How often do you take this medication?
    Less than once per weekOnce per week1-2 days per weekMost days per weekDailyMultiple times daily
  • Are you taking additional medication for your headaches?
  • Medication Name
  • How Long have you taken this medication?
  • How often do you take this medication?
    Less than once per weekOnce per week1-2 days per weekMost days per weekDailyMultiple times daily

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