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Please mark the correct
response: |
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I have a headache... |
1x per month |
2 - 4x per month
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More than 4x per month
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My headaches typically are... |
Mild |
Moderate |
Severe |
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The
purpose of the scale is to identify difficulties that you may be
experiencing because of your headache.
Please
check-off "Yes", "Sometimes" to each item. The default answer is set
to "No".
Answer
each question as it pertains to your headache, only.
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Yes |
Sometimes |
No |
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1 |
Because of my
headaches I feel handicapped. |
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2 |
Because of my
headaches I feel restricted in performing routine daily
activities. |
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3 |
No one
understands the effect my headaches have on my life. |
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4 |
I restrict
recreational activites (sports, hobbies) because of my
headaches. |
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5 |
My headaches
make me angry. |
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6 |
Sometimes I feel
I am going to lose control because of my headaches. |
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7 |
Because of my headaches, I am less likely to
socialize. |
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8 |
My spouse (significant other) or family and friends have no
idea what I'm going through because of my headaches. |
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9 |
My headaches are so bad that I think I am going to go
insane. |
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10 |
My outlook on the world is affected by my
headaches. |
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11 |
I am afraid to go outside when I feel that a headache is
starting |
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12 |
I feel desperate because of my headaches. |
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13 |
I am concerned that I am paying penalties at work or at home
because of my headaches. |
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14 |
My headaches place stress on my relationships with family or
friends. |
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15 |
I avoid being around people when I have a headache. |
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16 |
I believe my headaches make it difficult to achieve my goals
in life. |
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17 |
I am unable to think clearly because of my
headaches. |
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18 |
I get tense (muscle tension) because of my
headaches. |
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19 |
I do not enjoy social gatherings because of my
headaches. |
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20 |
I feel irritable because of my headaches. |
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21 |
I avoid travelling because of my headaches. |
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22 |
My headaches make me feel confused. |
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23 |
My headaches make me feel frustrated. |
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24 |
I find it difficult to read because of my headaches |
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25 |
I find it difficult to focus my attention away from my
headaches and on other things. |
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