Complete Chiropractic – Headache Disability Index Headache disability index This headache disability index form should be used if you have been directed to do so by your doctor. Part 1 About you Your Prefix *Mr.Mrs.Ms.Mx.MissDr.Prof. Your First Name * Your Last Name * Email Address * Section 2 Your headaches In 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 week My headaches are *MildModerateSevere The 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 *YesNoSometimes Because of my headaches I feel restricted in performing my routine daily activities. *YesNoSometimes No one understands the effect my headaches have on my life. *YesNoSometimes I restrict my recreational activities (eg. Sports, Hobbies) because of my headaches. *YesNoSometimes My headaches make me angry. *YesNoSometimes Sometimes I feel that I am going to lose control because of my headaches. *YesNoSometimes Because of my headaches I am less likely to socialize. *YesNoSometimes My Spouse (significant other), or family and friends have no idea what I am going through because of my headaches. *YesNoSometimes My headaches are so bad that I feel that feel that I am going to go insane. *YesNoSometimes My outlook on the world is affected by my headaches. *YesNoSometimes I am afraid to go outside when I feel that a headache is starting. *YesNoSometimes I feel desperate because of my headaches. *YesNoSometimes I am concerned that I am paying penalties at work or at home because of my headaches. *YesNoSometimes My headaches place stress on my relationships with family or friends. *YesNoSometimes I avoid being around people when I have a headache. *YesNoSometimes I believe my headaches are making it difficult for me to achieve my goals in life. *YesNoSometimes I am unable to think clearly because of my headaches. *YesNoSometimes I get tense (eg. Muscle tension) because of my headaches. *YesNoSometimes I do not enjoy social gatherings because of my headaches. *YesNoSometimes I feel irritable because of my headaches. *YesNoSometimes I avoid traveling because of my headaches. *YesNoSometimes My headaches make me feel confused. *YesNoSometimes My headaches make me feel frustrated. *YesNoSometimes I find it difficult to read because of my headaches. *YesNoSometimes I find it difficult to focus my attention away from my headaches and on other things. *YesNoSometimes Thank 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 condition Submit form Please do not fill in this field.
