Alliance MDS

Name: *

(as it is listed on your health-card)

First Name

Last Name

I have already scheduled a follow-up appointment for ... : *

MM

DD

YYYY

1. Feeling nervous, anxious, or on edge *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

2. Not being able to control or stop worrying *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

3. Feeling down, depressed or hopeless *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

4. Little interest or pleasure in doing things *

Not at all (0)

Several days (1)

More than half the days (2)

Nearly every day (3)

1. When you have headaches, how often is the pain severe? *

Never (6)

Rarely (8)

Sometimes (10)

Very Often (11)

Always (13)

2. How often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities? *

Never (6)

Rarely (8)

Sometimes (10)

Very Often (11)

Always (13)

3. When you have a headache, how often do you wish you could lie down? *

Never (6)

Rarely (8)

Sometimes (10)

Very Often (11)

Always (13)

4. In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches? *

Never (6)

Rarely (8)

Sometimes (10)

Very Often (11)

Always (13)

5. In the past 4 weeks, how oftenhave you felt fed up or irritated because of your headaches? *

Never (6)

Rarely (8)

Sometimes (10)

Very Often (11)

Always (13)

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

Never (6)

Rarely (8)

Sometimes (10)

Very Often (11)

Always (13)