Headache Disability Index

Full Name *

Today's Date: *

Section 1. INSTRUCTIONS: Please MARK the correct response:

I have a headache: *

1 per month (score: 1)

more than 1 but less than 4 per month (score: 2)

more than 1 per week (score: 3)

My headache is: *

Mild (score: 1)

Moderate (score: 2)

Severe (score: 3)

Section 1 Total

Section 2. INSTRUCTIONS: PLEASE READ CAREFULLY: The purpose of the scale is to identify difficulties that you may be experiencing because of your headaches. Please mark off “YES”, “SOMETIMES”, or “NO” to each item. Answer each item as it pertains to your headaches only.

Because of my headaches I feel handicapped. *

Yes-4

Sometimes-2

No-0

No one understands the effect my headaches have on my life. *

Yes-4

Sometimes-2

No-0

My spouse/significant other, or family and friends have no idea what I am going through because of my headaches. *

Yes-4

Sometimes-2

No-0

My headaches are so bad that I feel I am going to go insane.

Yes-4

Sometimes-2

No-0

Sometimes I feel that I am going to lose control because of my headaches. *

Yes-4

Sometimes-2

No-0

I am afraid to go outside when I feel a headache is starting. *

Yes-4

Sometimes-2

No-0

My headaches place stress on my relationships with family and friends. *

Yes-4

Sometimes-2

No-0

My headaches make me angry. *

Yes-4

Sometimes-2

No-0

My outlook on the world is affected by my headaches. *

Yes-4

Sometimes-2

No-0

My headaches make me feel desperate. *

Yes-4

Sometimes-2

No-0

My headaches make me feel frustrated. *

Yes-4

Sometimes-2

No-0

I feel irritable because of my headaches. *

Yes-4

Sometimes-2

No-0

I restrict my recreational activities (e.g. sports, hobbies) because of my headaches. *

Yes-4

Sometimes-2

No-0

My headaches make me feel confused. *

Yes-4

Sometimes-2

No-0

Because of my headaches I feel restricted in performing my routine daily activities. *

Yes-4

Sometimes-2

No-0

I avoid being around people when I have a headache. *

Yes-4

Sometimes-2

No-0

Because of my headaches I am less likely to socialize. *

Yes-4

Sometimes-2

No-0

I am unable to think clearly because of my headaches. *

Yes-4

Sometimes-2

No-0

I am concerned that I am paying penalties at work or at home because of my headaches. *

Yes-4

Sometimes-2

No-0

I believe my headaches are making it difficult for me to achieve my goals in life. *

Yes-4

Sometimes-2

No-0

I do not enjoy social gatherings because of my headaches. *

Yes-4

Sometimes-2

No-0

I get tense (e.g. muscle tension) because of my headaches. *

Yes-4

Sometimes-2

No-0

I find it difficult to read because of my headaches. *

Yes-4

Sometimes-2

No-0

I find it difficult to focus my attention away from my headaches and on other things. *

Yes-4

Sometimes-2

No-0

I avoid traveling because of my headaches. *

Yes-4

Sometimes-2

No-0

Section 2. For every 'yes' add 4 points, for every 'sometimes' add 2 points. Do not add any points for any 'no' responses.

Section 2 Total

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Captcha

Reference: Jacobson Gary P., Ramadan NM, et al., The Henry Ford Hospital Headache Disability Inventory (HDI). Neurology 1994; 44:837-842
FORM 502

Brain, Not Bone Alone

Get in Touch

Email:

[email protected]

Address:
26302 La Paz Road, Suite 214

Mission Viejo, CA 92691

Phone Number:

Call Office : 949-359-8385

Text Office: 949-619-6545

Hours of Operation

Monday | 9:00am – 5:30pm

Tuesday | 9:00am – 5:30pm

Wednesday | 7:30am – 11:30am

Thursday | 9:00am – 5:30pm

Friday | Closed

Sat & Sun | Closed

CLICK HERE TO PAY

26302 La Paz Road, Suite 214

Mission Viejo, CA 92691

Superbill Request

Insurance Verification

Terms & Conditions

Copyright 2024. All rights reserved.