File number:

/___ /___ /___/

I. SOCIO-PROFESSIONAL DATA

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: ..........................................................................................

Q06. Professional category: 1. white collar; 2. blue collar

/___/

Q07. Position held.....................................................................................

Q08. Length of service (in years)............................................................

Q09. Company: ...............................................................................................................

Q10. Sector: 1. Public 2. Private

/___/

Q11. Type of activity: ....................................................................................................

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

II.1 Background:

Q16. HTA: 1. Yes 2. No

/___/

Q17. Migraine: 1. Yes 2. No

If yes, stop interview

/___/

Q18. Do you take:

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): ..........................

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

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

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: ..............................

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:

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:

Q36. a. Visual problems: 1. Yes 2. No

/___/

Q36. b. Sensory or motor: 1. Yes 2. No

/___/

Q37. Headache triggers:

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):

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):

Q44. Impact: 1. Slight to moderate 2. Severe

/___/

Q45. Number of days absent in a year: ..................................