Headache Disability Index Questionnaire

This questionnaire has been designed to provide information as to how your headaches affect your ability to manage in everyday life.

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

Please read this Disclaimer of Liability, then click on one of the following statements to proceed with the online self-assessment:

• I have read and understand the disclaimer, and I agree to hold www.bhpw.com and its contractors, subcontractors, agents, servants and employees harmless from and against any and all claims, actions, damages, liability and/or expenses in connection with damage arising from or out of my voluntary election to continue viewing and/or using the Better Health Pain and Wellness Centers web-site. I also confirm that I have discussed the use of this site in detail with my treating physician and that I have obtained his/her approval to proceed.

• I do not understand, or do not agree with the disclaimer.