Quality of Life Questionnaire
  Home
  Bookings
  Contact us
  Quality of Life
  Diagnosis
  Find us
  FAQs
  Medication Overuse
  Free Assistance
  Events
 

 

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 within 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?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

2. In the past 4 weeks, how often have the headaches interfered with your leisure time activities, such as reading and exercising?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

3. In the past 4 weeks, how often have you had difficulty in performing work or daily activities because of headache?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

4. In the past 4 weeks, how often did the headaches keep you from getting as much done at work or at home?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

5. In the past 4 weeks, how often did the headaches limit your ability to concentrate on work or daily activities?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

6. In the past 4 weeks, how often have headaches left you too tired to do work or daily activities?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

7. In the past 4 weeks, how often have headaches limited the number of days you have felt energetic?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

8. In the past 4 weeks, how often have you had to cancel work or daily activities because you had a headache?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

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?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

10. In the past 4 weeks, how often have you had to stop work or daily activities to deal with headache symptoms?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

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?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

12. In the past 4 weeks, how often have you felt fed up or frustrated because of your headaches?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

13. In the past 4 weeks, how often have you felt like you were a burden on others because of your headaches?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

14. In the past 4 weeks, how often have you been afraid of letting others down because of your headaches?
None of the time
A little bit of the time
Some of the time
A good bit of the time
Most of the time
All of the time

 


Cape Town | Durban | Johannesburg 		 


Tel: 0861 678 911 . . International +27 11 484 0933