Headache
Disability Index
Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
INSTRUCTIONS: Please CIRCLE the correct response:1. I have headache: (1) 1 per month (2) more than 1 but less than 4 per month (3) more than one per week 2. My headache is: (1) mild (2) moderate (3) severePlease 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.
Because of my headaches I feel disabled.
Yes
No
Sometimes
Because of my headaches I feel restricted in performing my routine daily activities.
Yes
No
Sometimes
No one understands the effect my headaches have on my life.
Yes
No
Sometimes
I restrict my recreational activities (eg, sports, hobbies) because of my headaches.My
Yes
No
Sometimes
Headaches make me angry.
Yes
No
Sometimes
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Next
Sometimes I feel that I am going to lose control because of my headaches.
Yes
No
Sometimes
Because of my headaches I am less likely to socialize.
Yes
No
Sometimes
My spouse (significant other), or family and friends have no idea what I am going through because of my headaches.
Yes
No
Sometimes
My headaches are so bad that I feel that I am going to go insane.
Yes
No
Sometimes
My outlook on the world is affected by my headaches.
Yes
No
Sometimes
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I am afraid to go outside when I feel that a headaches is starting.
Yes
No
Sometimes
I feel desperate because of my headaches.
Yes
No
Sometimes
I am concerned that I am paying penalties at work or at home because of my headaches.
Yes
No
Sometimes
My headaches place stress on my relationships with family or friends.
Yes
No
Sometimes
I avoid being around people when I have a headache.
Yes
No
Sometimes
I believe my headaches are making it difficult for me to achieve my goals in life.I am
Yes
No
Sometimes
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Next
I am unable to think clearly because of my headaches
Yes
No
Sometimes
.I get tense (eg, muscle tension) because of my headaches.
Yes
No
Sometimes
I do not enjoy social gatherings because of my headaches.
Yes
No
Sometimes
I feel irritable because of my headaches.
Yes
No
Sometimes
Back
Next
I avoid traveling because of my headaches.
yes
No
Sometimes
My headaches make me feel confused.
Yes
No
Sometimes
My headaches make me feel frustrated.
Yes
No
Sometimes
I find it difficult to read because of my headaches.
Yes
No
Sometimes3
I find it difficult to focus my attention away from my headaches and on other things.
Yes
No
Sometimes
Instructions: 1. Using this system, if "YES" is checked on any given line, that answer is given 4 points... a "SOMETIMES" answer is given 2 points and a "NO" answer is given zero. 2. Using this system, a score of 10-28% is considered to constitute mild disability; 30-48% is moderate; 50-68% is severe; 72% or more is complete.
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