Quality of Life Questionnaire

Severe and chronic headaches are common causes of reduced productivity, depression, feeling of helplessness, relationship strain, and even loss of employment and relationship breakdown. The Quality Of Life questionnaire measures the extent to which headaches are affecting your ability to function normally from three specific angles. Filling out the questionnaire will tell you :

  • The percentage of time that you are able to function
  • The percentage output that you are able to give when you continue to function despite your headache pain.
  • The percentage of your emotional function at which your headaches allow you to operate.

The questionnaire has been designed so that it can be completed quickly and easily. Please choose only one answer for each question. You should answer every question to ensure the most accurate results.

THE QUALITY OF LIFE ASSESSMENT IS PROVIDED BY THE HEADACHE CLINIC AS A FREE SERVICE TO HEADACHE SUFFERERS

Please complete the form at the end of the questionnaire to enable us to process the results of the Quality of Life Assessment. The results should appear on your screen with a few seconds of you completing the form.

1. In the past 4 weeks, how often have the headaches interfered with how well you dealt with your family, friends, and others who are close to you? (Select only one response)

2. In the past 4 weeks, how often have the headaches interfered with your leisure time activities, such as reading and exercising?

3. In the past 4 weeks, how often have you had difficulty in performing work or daily activities because of headache?

4. In the past 4 weeks, how often did the headaches keep you from getting as much done at work or at home?

5. In the past 4 weeks, how often did the headaches limit your ability to concentrate on work or daily activities?

6. In the past 4 weeks, how often have headaches left you too tired to do work or daily activities?

7. In the past 4 weeks, how often have headaches limited the number of days you have felt energetic?

8. In the past 4 weeks, how often have you had to cancel work or daily activities because you had a headache?

9. In the past 4 weeks, how often did you need help in handling routine tasks such as every day household chores, doing necessary business, shopping, or caring for others, when you had a headache?

10. In the past 4 weeks, how often have you had to stop work or daily activities to deal with headache symptoms?

11. In the past 4 weeks, how often were you not able to go to social activities such as parties, dinner with friends, because you had a headache?

12. In the past 4 weeks, how often have you felt fed up or frustrated because of your headaches?

13. In the past 4 weeks, how often have you felt like you were a burden on others because of your headaches?

14. In the past 4 weeks, how often have you been afraid of letting others down because of your headaches?