HEADACHE DISABILITY INDEX QUESTIONNAIRE

Name:____________________

Ref. Dr:___________________

Date: _______

ID#: _______________

Age: _______

Gender: M / F

INSTRUCTIONS: Please CHECK the correct response:
1. I have headaches: 1 per month more than 1 but less than 4 per month more than 1 per week
2. My headache is: mild moderate severe

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

	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.