This questionaire is used to determine the level of pain & disability caused by your headaches
and helps us find the best treatment for you. You may print this form, then fill it out and bring it
with you on your office visit.

1. On how many days in the last 3 months did you miss work or school because of your headache?
(if you do not attend school or work, enter zero)..........................................................________

2. How many days in the last 3 months was your productivity at work or school reduced by half
because of your headaches?(Do not include days you counted in question 1 where you missed work
or school).................................................................................................................________

3. On how many days in the last 3 months did you not do household work because of your
headaches?...............................................................................................................________

4. How many days in the last 3 months was your productivity in household work reduced by half
or more because of your headaches? (Do not include days counted in Question 3, where you did
not do housework)....................................................................................................________

5. On how many days in the last 3 months did you miss family, social, or leisure activities because
of your headaches?...................................................................................................________

Scoring:

    Add the total number of days from questions 1-5:

                    Grade                  Definition                Score
                          I                    Little or no Disability             0-5
                         I I                       Mild Disability                  6-10
                        I I I                  Moderate Disability              11-20
                         I V                   Severe Disability                   21+

6. On how many days in the last 3 months did you have a headache? (If your headache lasted more
than 1 day, count each day).......................................................................................________

7. On a scale of 1-10, on average, how painful were these headaches? (Where 0=no pain at all, and
10=pain which is as bad as it can be.)........................................................................._________