My Headache Disability Assessment

Self Assessment - Headache

Having Headaches?

Fill this form to assess the impact and disability due to headaches.

Undergoing Headache or Migraine treatment?

Assess your outcomes by filling this form before starting your treatment and then at every 4 weeks during the treatment to know how you are doing with the treatment.

You can also fill this form, twice a year, just to keep a check!

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Name
Name
First
Last
During headaches, how often is the pain severe?
During headaches, how often you wish that you could lie down?
How often your headaches limit your ability to do usual daily activities (includes household chores, work, school, or social activities)?
How often your headaches made you feel fed up or irritated, in the past 4 weeks?
How often your headaches made you feel too tired to do work or daily activities, in the past 4 weeks?
How often your headaches limited your ability to concentrate on work or daily activities, in the past 4 weeks?
Here 0=no pain at all and 10=pain as bad as it can be.
Are you taking any medication for this issue?
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