File number: | /___ /___ /___/ |
I. SOCIO-PROFESSIONAL DATA |
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Q01. Gender: 1. Male 2. Female | /___/ |
Q02. Age: | /___ /___/ |
Q03. Level of education: 1. Primary 2. Secondary 3. Higher | /___/ |
Q04. Marital status: 1. Single 2. Married 3. Divorced 4. Widowed 5. Cohabiting | /___/ |
Q05. Profession: .......................................................................................... |
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Q06. Professional category: 1. white collar; 2. blue collar | /___/ |
Q07. Position held..................................................................................... |
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Q08. Length of service (in years)............................................................ |
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Q09. Company: ............................................................................................................... |
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Q10. Sector: 1. Public 2. Private | /___/ |
Q11. Type of activity: .................................................................................................... |
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Q12. Type of employment contract: 1. Fixed-term 2. CDI | /___/ |
Q13. Hourly volume: 1. Normal 2. High | /___/ |
Q14. Workload: 1. Low 2. Normal 3. High | /___/ |
Q15. Socio-economic level: 1. Very low 2. Low 3. High 4. Very high | /___/ |
II. CLINICAL DATA |
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II.1 Background: |
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Q16. HTA: 1. Yes 2. No | /___/ |
Q17. Migraine: 1. Yes 2. No If yes, stop interview | /___/ |
Q18. Do you take: |
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Q19. a. Alcohol: 1. Yes 2. No | /___/ |
Q19. b. Tobacco: 1. Yes 2. No | /___/ |
Q19. c. Narcotics: 1. Yes 2. No | /___/ |
Q19. Headaches in the family: 1. Yes 2. No | /___/ |
Q20. Do you often suffer from headaches: 1. Yes 2. No | /___/ |
Q21. If yes, since when: 1. Less than 3 months 2. More than 3 months If less than 3 months stop interviewing | /___/ |
Q22. If more than 3 months, please estimate the duration (in months): .......................... |
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Q23. Regular use of medication (antidepressants, estrogens, NSAIDs, painkillers): 1. Yes 2. No | /___/ |
Q24. If yes, does the onset of headache coincide with the use of this/these medication(s)? 1. Yes 2. No If yes, stop interview | /___/ |
II.2 Headache characteristics |
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Q25. Where is your pain located? 1. One side 2. The whole head 3. One side then the other | /___/ |
Q26. If one side: 1. Occipital 2. Parietal 3. Temporal 4. Temporo-orbital 5. Parieto-temporal 6. Vertex |
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Q27. What does your pain feel like? 1. Tapping 2. Burning 3. Squeezing 4. Grinding 5. It weighs. 6. Like a shock 7. Like a stab wound | /___/ |
Q28. How would you rate the intensity of your pain (VAS)? 1. Mild 2. Moderate 3. Severe 4. Very severe | /___/ |
Q29. How does your headache evolve: 1. In attacks 2. Continuously | /___/ |
Q30: If seizure, duration: 1. 30 minutes to 7 days 2. More than 7 days 3. Less than 30 minutes | /___/ |
Q31. How frequent are your seizures? 1. Daily 2. Weekly 3. Monthly 4. Irregular | /___/ |
Q32. Number of crises per month: .............................. |
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Q33. Average number of headache days per month: 1. Less than one day 2. 1 - 14 days 3. More than 14 days | /___/ |
Q34. Is your headache aggravated by routine physical activities (walking, climbing, etc.)? stairs...)? 1. Yes 2. No | /___/ |
Q35. Is your headache accompanied by: |
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Q35. a. Feel like vomiting: 1. Yes 2. No | /___/ |
Q35. b. Vomiting: 1. Yes 2. No | /___/ |
Q35. c. Light sensitivity: 1. Yes 2. No | /___/ |
Q35. d. Noise annoyance: 1. Yes 2. No | /___/ |
Q35. e. Pericranial sensitivity: 1. Yes 2. No | /___/ |
Q36. Is your headache preceded or accompanied by: |
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Q36. a. Visual problems: 1. Yes 2. No | /___/ |
Q36. b. Sensory or motor: 1. Yes 2. No | /___/ |
Q37. Headache triggers: |
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Q37. a. Annoyance/stress: 1. Yes 2. No | /___/ |
Q37. b. Hormonal factors (menstruation, oral contraception): 1. Yes 2. No | /___/ |
Q37. c. Dietary factors (chocolate, other): 1. Yes 2. No | /___/ |
Q37. d. Sensory factors (flashing light, scratched decor, noise, smell): 1. Yes 2. No | /___/ |
Q37. e. Prolonged sleep: 1. Yes 2. No | /___/ |
Q37. f. Hypoglycemia: 1. Yes 2. No | /___/ |
Q37. g. Heat: 1. Yes 2. Yes | /___/ |
II.3 Psychosocial factors at work (Karasek questionnaire): |
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Q38. Decision-making latitude: 1. Low 2. High | /___/ |
Q39. Psychological demand: 1. Low 2. High | /___/ |
Q40. Social support: 1. Low 2. Normal | /___/ |
Q41. Psychological state: 1. Stressed 2. Active 3. Relaxed 4. Passive | /___/ |
Q42. Stressful work situation: 1. Yes 2. Yes | /___/ |
Q43. Workplace well-being: 1. Yes 2. No | /___/ |
III INDIVIDUAL IMPACT (HTI-6 score): |
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Q44. Impact: 1. Slight to moderate 2. Severe | /___/ |
Q45. Number of days absent in a year: .................................. |
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