Warning: include(/home/chiroAdmin/www/chirodids.php) [function.include]: failed to open stream: No such file or directory in D:\Hosting\7372557\html\drbeaversbhc\headache_request_form.php on line 1

Warning: include() [function.include]: Failed opening '/home/chiroAdmin/www/chirodids.php' for inclusion (include_path='.;C:\php5\pear') in D:\Hosting\7372557\html\drbeaversbhc\headache_request_form.php on line 1
  Home About Us Family Health Health Tour & Health Tests Contact Us  

Better Health Chiropractic

   
 

Dr. Jeffery G. Beavers, DC

 

 

Headache Questionaire

First Name:
Last Name:
Age:
Address:
City:
State:
Zip:
Phone:
Fax:
Email Address:

Please mark the correct response:
I have a headache...

1x per month

2 - 4x per month


More than 4x per month

My headaches typically are...

Mild

Moderate

Severe
 

The purpose of the scale is to identify difficulties that you may be experiencing because of your headache.

Please check-off 'Yes', 'Sometimes' to each item. The default answer is set to 'No'.

Answer each question as it pertains to your headache, only.

       
Yes
Sometimes
No
1
Because of my headaches I feel handicapped.
2
Because of my headaches I feel restricted in performing routine daily activities.
3
No one understands the effect my headaches have on my life.
4
I restrict recreational activites (sports, hobbies) because of my headaches.
5
My headaches make me angry.
6
Sometimes I feel I am going to lose control because of my headaches.
7
Because of my headaches, I am less likely to socialize.
8
My spouse (significant other) or family and friends have no idea what I'm going through because of my headaches.
9
My headaches are so bad that I think I am going to go insane.
10
My outlook on the world is affected by my headaches.
11
I am afraid to go outside when I feel that a headache is starting
12
I feel desperate because of my headaches.
13
I am concerned that I am paying penalties at work or at home because of my headaches.
14
My headaches place stress on my relationships with family or friends.
15
I avoid being around people when I have a headache.
16
I believe my headaches make it difficult to achieve my goals in life.
17
I am unable to think clearly because of my headaches.
18
I get tense (muscle tension) because of my headaches.
19
I do not enjoy social gatherings because of my headaches.
20
I feel irritable because of my headaches.
21
I avoid travelling because of my headaches.
22
My headaches make me feel confused.
23
My headaches make me feel frustrated.
24
I find it difficult to read because of my headaches
25
I find it difficult to focus my attention away from my headaches and on other things.

Would you like to hear the results of your assessment and the recommendations of care via the telephone or email?
Telephone Email


 
   
Home  |  About Us  |  Family Health  |  Health Tour & Health Tests  |  Contact Us

Copyright © 2007 CPMS and ChiroPower, LLC