Complete Chiropractic – Headache Disability Index Headache disability indexThis headache disability index form should be used if you have been directed to do so by your doctor. Part 1 About youYour Prefix *Mr.Mrs.Ms.Mx.MissDr.Prof.Your First Name *Your Last Name *Email Address *Section 2 Your headachesIn this section, we'd like to get an understanding of any previous health issues you have had, which might impact on your current problem.How do your headaches impact you? I have headaches *Once per monthMore than one, but less then four per month More than one per weekMy headaches are *MildModerateSevereThe purpose of the scale is to identify difficulties that you may be experiencing because of your headache. Please choose off “YES”, “SOMETIMES”, or “NO” for each item. Answer each question as it pertains to your headache only.Because of my headaches I feel handicapped *YesNoSometimesBecause of my headaches I feel restricted in performing my routine daily activities. *YesNoSometimesNo one understands the effect my headaches have on my life. *YesNoSometimesI restrict my recreational activities (eg. Sports, Hobbies) because of my headaches. *YesNoSometimesMy headaches make me angry. *YesNoSometimesSometimes I feel that I am going to lose control because of my headaches. *YesNoSometimesBecause of my headaches I am less likely to socialize. *YesNoSometimesMy Spouse (significant other), or family and friends have no idea what I am going through because of my headaches. *YesNoSometimesMy headaches are so bad that I feel that feel that I am going to go insane. *YesNoSometimesMy outlook on the world is affected by my headaches. *YesNoSometimesI am afraid to go outside when I feel that a headache is starting. *YesNoSometimesI feel desperate because of my headaches. *YesNoSometimesI am concerned that I am paying penalties at work or at home because of my headaches. *YesNoSometimesMy headaches place stress on my relationships with family or friends. *YesNoSometimesI avoid being around people when I have a headache. *YesNoSometimesI believe my headaches are making it difficult for me to achieve my goals in life. *YesNoSometimesI am unable to think clearly because of my headaches. *YesNoSometimesI get tense (eg. Muscle tension) because of my headaches. *YesNoSometimesI do not enjoy social gatherings because of my headaches. *YesNoSometimesI feel irritable because of my headaches. *YesNoSometimesI avoid traveling because of my headaches. *YesNoSometimesMy headaches make me feel confused. *YesNoSometimesMy headaches make me feel frustrated. *YesNoSometimesI find it difficult to read because of my headaches. *YesNoSometimesI find it difficult to focus my attention away from my headaches and on other things. *YesNoSometimesThank you for completing the headache disability form. Please check the box below to indicate you have read our privacy policy and then press "Submit".GDPR *Yes, I agree with privacy policy, terms and conditionSubmit formPlease do not fill in this field.
