Pain Disability Index - Dr. Reid Friesen

Does your pain interfere with your normal work inside and outside the home?

Work normally
0
1
2
3
4
5
6
7
8
9
10
Unable to work at all

Does your pain interfere with personal care (such as washing, dressing, etc.)?

Does your pain interfere with your traveling?

Does pain affect your ability to sit or stand?

Does your pain affect your ability to lift overhead, grasp objects, or reach for things?

Does your pain affect your ability to lift objects off the floor, bend, stoop or squat?

Does your pain affect your ability to walk or run?

Has your income declined since your pain began?

Do you have to take pain medication every day to control your pain?

Does your pain force you to see doctors much more often than before your pain began?

Does your pain interfere with your ability to see the people who are important to you as much as you would like?

Does your pain interfere with recreational activates and hobbies that are import to you?

Do you need the help of your family and friends to complete everyday tasks (including both work outside the home and housework) because of your pain?

Do you now feel more depressed, tense, or anxious than before your pain began?

Are there emotional problems caused by your pain that interfere with your family, social and / or work activities?

Headache Disability Questionnaire (HDQ)

Please answer the following questions about ALL of the headaches you have had over the last 3 months. Select your answer in the box next to each question. Select Zero if you did not have the activity in the last 3 months. Please take the completed form to your healthcare professional.

On how many days in the last 3 months did you miss work or school because of your headaches?