Headache Disability Index | Fielding Law Group

Please select the most accurate response regarding your headaches*
Please select the most accurate response regarding your headaches
- I have headaches ONCE per month
- I have headaches MORE than once per month but LESS than four times per month
- I have headaches MORE than ONCE per WEEK

Please select the most accurate response regarding your headaches*
Please select the most accurate response regarding your headaches
- My headache is mild
- My headache is moderate
- My headache is severe

The purpose of the scale is to identify difficulties that you may be experiencing because of your headache. Please select “YES”, “SOMETIMES”, or “NO” 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 disabled.
- Yes
- Sometimes
- No

Because of my headaches I feel restricted in performing my routine daily activities.*
Because of my headaches I feel restricted in performing my routine daily activities.
- Yes
- Sometimes
- No

No one understands the effect my headaches have on my life.*
No one understands the effect my headaches have on my life.
- Yes
- Sometimes
- No

I restrict my recreational activities (eg, sports, hobbies) because of my headaches.*
I restrict my recreational activities (eg, sports, hobbies) because of my headaches.
- Yes
- Sometimes
- No

My headaches make me angry.*
My headaches make me angry.
- Yes
- Sometimes
- No

Sometimes I feel that I am going to lose control because of my headaches.*
Sometimes I feel that I am going to lose control because of my headaches.
- Yes
- Sometimes
- No

Because of my headaches I am less likely to socialize.*
Because of my headaches I am less likely to socialize.
- Yes
- Sometimes
- No

My spouse (significant other), or family and friends have no idea what I am going through because of my headaches.*
My spouse (significant other), or family and friends have no idea what I am going through because of my headaches.
- Yes
- Sometimes
- No

My headaches are so bad that I feel that I am going to go insane.*
My headaches are so bad that I feel that I am going to go insane.
- Yes
- Sometimes
- No

My outlook on the world is affected by my headaches.*
My outlook on the world is affected by my headaches.
- Yes
- Sometimes
- No

I am afraid to go outside when I feel that a headaches is starting.*
I am afraid to go outside when I feel that a headaches is starting.
- Yes
- Sometimes
- No

I feel desperate because of my headaches.*
I feel desperate because of my headaches.
- Yes
- Sometimes
- No

I am concerned that I am paying penalties at work or at home because of my headaches.*
I am concerned that I am paying penalties at work or at home because of my headaches.
- Yes
- Sometimes
- No

My headaches place stress on my relationships with family or friends.*
My headaches place stress on my relationships with family or friends.
- Yes
- Sometimes
- No

I avoid being around people when I have a headache.*
I avoid being around people when I have a headache.
- Yes
- Sometimes
- No

I believe my headaches are making it difficult for me to achieve my goals in life.*
I believe my headaches are making it difficult for me to achieve my goals in life.
- Yes
- Sometimes
- No

I am unable to think clearly because of my headaches.*
I am unable to think clearly because of my headaches.
- Yes
- Sometimes
- No

I get tense (eg, muscle tension) because of my headaches.*
I get tense (eg, muscle tension) because of my headaches.
- Yes
- Sometimes
- No

I do not enjoy social gatherings because of my headaches.*
I do not enjoy social gatherings because of my headaches.
- Yes
- Sometimes
- No

I feel irritable because of my headaches.*
I feel irritable because of my headaches.
- Yes
- Sometimes
- No

I avoid traveling because of my headaches.*
I avoid traveling because of my headaches.
- Yes
- Sometimes
- No

My headaches make me feel confused.*
My headaches make me feel confused.
- Yes
- Sometimes
- No

My headaches make me feel frustrated.*
My headaches make me feel frustrated.
- Yes
- Sometimes
- No

I find it difficult to read because of my headaches.*
I find it difficult to read because of my headaches.
- Yes
- Sometimes
- No

I find it difficult to focus my attention away from my headaches and on other things.*
I find it difficult to focus my attention away from my headaches and on other things.
- Yes
- Sometimes
- No

Please describe how your headaches affect your daily life activities*
Please describe how your headaches affect your daily life activities

Are you taking medication for your headaches?*
Are you taking medication for your headaches?
- Yes
- No

Medication Name*
Medication Name
How Long have you taken this medication?*
How Long have you taken this medication?
How often do you take this medication?*
How often do you take this medication?
Less than once per week Once per week 1-2 days per week Most days per week Daily Multiple times daily
Are you taking additional medication for your headaches? 1*
Are you taking additional medication for your headaches?
- Yes
- No
Medication Name*
Medication Name
How Long have you taken this medication?*
How Long have you taken this medication?
How often do you take this medication?*
How often do you take this medication?
Less than once per week Once per week 1-2 days per week Most days per week Daily Multiple times daily
Are you taking additional medication for your headaches? 2*
Are you taking additional medication for your headaches?
- Yes
- No
Medication Name*
Medication Name
How Long have you taken this medication?*
How Long have you taken this medication?
How often do you take this medication?*
How often do you take this medication?
Less than once per week Once per week 1-2 days per week Most days per week Daily Multiple times daily