INSTRUCTIONS'

INSTRUCTIONS
Please answer the following questions about ALL your headaches you have had over the last 3 months. Write your answer in the box next to each question. 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 headache?	__ __ days
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)	__ __ days
3	On how many days in the last 3 months did you not do househoid work because of your headache?	__ __ days
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)	__ __ days
5	On how many days in the last 3 months did you miss family, social, or leisure activities because of your headaches?	__ __ days

A	On how many days in the last 3 months did you have a headache? (lf a headache lasted more than 1 day, count each day)	__ __ days
B	On a scale of 0 -10, on average how painful were these headaches? (Where 0 = no pain at all, and 10 = pain as bad as can it be)	__ __ pain