HEADACHE DISABILITY INDEX QUESTIONNAIRE SOFTWARE

Patient Name: ____________________	Ref. Dr.: _______________
Date of Test: _________

Please CHECK the correct response:

1.  I have headaches:	q1 per month	q more than 1 but less than 4 per month 	q more than 1 per  week 
2.  My headache is:	q mild		q moderate	q severe 

INSTRUCTIONS:   (Please read carefully): The purpose of the scale is to identify difficulties that you may be experiencing because of your headache.  Please CIRCLE  "YES," "SOMETIMES," or "NO" to each item.  Answer each question as it pertains to your headache only.

E1.  Because of my headaches I feel handicapped.							Yes     Sometimes     No

F2.  Because of my headaches I feel restricted in performing my routine daily activities.			Yes     Sometimes     No

E3.  No one understands the effect my headaches have on my life.					Yes     Sometimes     No

F4.  I restrict my recreational activities (eg, sports, hobbies) because of my headaches.			Yes     Sometimes     No

E5.  My headaches make me angry.									Yes     Sometimes     No

E6.  Sometimes I feel that I am going to lose control because of my headaches. 			Yes     Sometimes     No

F7.  Because of my headaches I am less likely to socialize.						Yes     Sometimes     No

E8.   My spouse (significant other), or family and friends have no idea what I am going through because of my headaches.   Yes     Sometimes     No

E9.  My headaches are so bad that I feel that I am going to go insane.					Yes     Sometimes     No

E10.  My outlook on the world is affected by my headaches.						Yes     Sometimes     No

E11.  I am afraid to go outside when I feel that a headache is starting.					Yes     Sometimes     No

E12.  I feel desperate because of my headaches.							Yes     Sometimes     No

F13.  I am concerned that I am paying penalties at work or at home because of my headaches. 		Yes     Sometimes     No

E14.  My headaches place stress on my relationships with family or friends. 				Yes     Sometimes     No

F15.  I avoid being around people when I have a headache.						Yes     Sometimes     No

F16.  I believe my headaches are making it difficult for me to achieve my goals in life. 			Yes     Sometimes     No

F17.  I am unable to think clearly because of my headaches.						Yes     Sometimes     No

F18.  I get tense (eg, muscle tension) because of my headaches. 					Yes     Sometimes     No

F19.  I do not enjoy social gatherings because of my headaches. 					Yes     Sometimes     No

E20.  I feel irritable because of my headaches. 							Yes     Sometimes     No

F21.  I avoid traveling because of my headaches. 							Yes     Sometimes     No

E22.  My headaches make me feel confused. 							Yes     Sometimes     No

E23.  My headaches make me feel frustrated. 							Yes     Sometimes     No

F24.  I find it difficult to read because of my headaches. 						Yes     Sometimes     No

F25.  I find it difficult to focus my attention away from my headaches and on other things.  		Yes     Sometimes     No