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| Never (6 points) | Rarely (8 points) | Sometimes (10 points) | Very often (11 points) | Constantly (13 points) |
| 1-When you have headaches, is the pain intense? |
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| 2-Is your ability to carry out your usual daily activities (household chores, work, study or activities with others) limited because of your headaches? |
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| 3-When you have headaches, would you like to be able to lie down? |
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| 4-In the past 4 weeks, have you felt too tired to work or carry out your daily activities because of your headaches? |
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| 5-In the past 4 weeks, have you experienced a feeling of “ras-le-bol” or annoyance because of your headaches? |
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| 6-Over the past 4 weeks, has your ability to concentrate on your work or daily activities been limited because of your headaches? |
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| TOTAL |
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