Name:____________________ | Ref. Dr:___________________ | Date: _______ |
ID#: _______________ | Age: _______ | Gender: M / F |
YES | SOMETIMES | NO | |
E1. Because of my headaches I feel handicapped. | |||
F2. Because of my headaches I feel restricted in performing my routine daily activities. | |||
E3. No one understands the effect my headaches have on my life. | |||
F4. I restrict my recreational activities (eg, sports, hobbies) because of my headaches. | |||
E5. My headaches make me angry. | |||
E6. Sometimes I feel that I am going to lose control because of my headaches. | |||
F7. Because of my headaches I am less likely to socialize. | |||
E8. My spouse (significant other), or family and friends have no idea what I am going through because of my headaches. | |||
E9. My headaches are so bad that I feel that I am going to go insane. | |||
E10. My outlook on the world is affected by my headaches. | |||
E11. I am afraid to go outside when I feel that a headache is starting. | |||
E12. I feel desperate because of my headaches. | |||
F13. I am concerned that I am paying penalties at work or at home because of my headaches. | |||
E14. My headaches place stress on my relationships with family or friends. | |||
F15. I avoid being around people when I have a headache. | |||
F16. I believe my headaches are making it difficult for me to achieve my goals in life. | |||
F17. I am unable to think clearly because of my headaches. | |||
F18. I get tense (eg, muscle tension) because of my headaches. | |||
F19. I do not enjoy social gatherings because of my headaches. | |||
E20. I feel irritable because of my headaches. | |||
F21. I avoid traveling because of my headaches. | |||
E22. My headaches make me feel confused. | |||
E23. My headaches make me feel frustrated. | |||
F24. I find it difficult to read because of my headaches. | |||
F25. I find it difficult to focus my attention away from my headaches and on other things. |