New England Center for Headache

The following is a brief questionnaire developed by Dr. Richard Lipton. It is designed to help you communicate the impact of your headaches on your functional capacity and quality of life. Please fill this out so that we can tabulate the results.

Basic Information

Name:		Sex:
Email:		Age:
Onset Age:	(when you can first recall experiencing migranes)

Questions

1.	On how many days in the last 3 months have you had a headache?	1.

2.	How would you rate the pain from your headaches on a scale from 0 to 10 (0 is 'no pain at all' and 10 is 'pain as bad as it can be')?	2.
3.	How many days in the last 3 months have you been kept from work activities (work or school) for at least half of the day because of your headaches?	3.

4.	When you have a headache while you work (work or school), how much is your ability to work reduced? (0% is 'not reduced at all' and 100% is 'unable to work')	4.

5.	How many days in the last 3 months have you been kept from doing housework or chores for at least half of the day because of your headaches?	5.

6.	How much is your ability to do housework or chores reduced? (0% is 'not reduced at all' and 100% is 'unable to work').	6.

7.	How many days in the last 3 months have you been kept from non-work activities (family, social or recreational) because of your headaches?	7.

8.	How much is your ability to engage in non-work activities (family, social or recreational) reduced? (0% is 'not reduced at all' and 100% is 'unable to do activities').	8.

9.	How many emergency room visits have you had in the past 3 months?	9.