INSTRUCTIONS: Please answer the following questions about ALL the headaches you have had over the last 3 months. Write zero if you did not do the activity in the last 3 months. 1. On how many days in the last 3 months did you miss work or school because of your headaches? 2. How many days in the last 3 months was your productivity at work or school reduced by half or more because of your headaches (do not include days you counted in question 1 where you missed work or school)? 3. On how many days in the last 3 months did you not do household work because of your headaches? 4. How many days in the last 3 months was your productivity in household work reduced by half or more because of your headaches (do not include days you counted in question 3 where you did not do household work)? 5. On how many days in the last 3 months did you miss family, social, or leisure activities because of your headaches? 6. On how many days in the last 3 months did you have a headache? (If a headache lasted more than one day, count each day). 7. On a scale of 0-10, on average how painful were these headaches? (0 = no pain at all, 10 = pain as bad as it can be) Migraine Disability Assessment Score (Questions 1 -5 are used to calculate the MIDAS score). Grade I - Minimal or Infrequent Disability: 0-5 Grade II - Mild or Infrequent Disability: 6-10 Grade III - Moderate Disability: 11-20 Grade IV - Severe Disability: > 20This questionnaire was designed to help you describe and communicate the way you feel and what you cannot do because of headaches. Your HIT-6 results will be communicated with our medical team. When you have headaches, how often is the pain severe? Never (6) Rarely (8) Sometimes (10) Very Often (11) Always (13) None How often do headaches limit your ability to do usual daily activities including household work, work, school or social activities? Never (6) Rarely (8) Sometimes (10) Very Often (11) Always (13) None When you have a headache, how often do you wish you could lie down? Never (6) Rarely (8) Sometimes (10) Very Often (11) Always (13) None In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches? Never (6) Rarely (8) Sometimes (10) Very Often (11) Always (13) None In the past 4 weeks, how often have you felt fed up or irritated because of your headaches? Never (6) Rarely (8) Sometimes (10) Very Often (11) Always (13) None In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities? Never (6) Rarely (8) Sometimes (10) Very Often (11) Always (13) None First Name Last Name Email Phone Date of Birth Time's up
