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Get Headache Questionnaire (to Be Completed By ... - Bmo.com

Head is usually affected: 5. Are there any associated symptoms or signs affecting: 6. BMO Life Assurance Company 60 Yonge Street, Toronto, ON M5E 1H5 1-877-742-5244 416-596-4143 Fax PRINT Intermittent When was the last attack? Continuous Front Brief Prolonged Top Back Sides Vision, visual fields, double vision Unsteadiness of gait or limbs, staggering Numbness, tingling Undue sleepiness Muscle weakness Kidney disorder Nausea, vomiting Fits Dizziness, hearing loss High.

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How old were you when you first began to have headaches bad enough to interfere with your normal daily activities? How many headache days have you had in the past 30 days? How many of these days were headaches severe? Do you have daily headaches?

The Migraine Disability Assessment Scale (MIDAS) is a brief tool that is scored in units of lost days because of headache over 3 months in the domains of work and school, household work and chores, and family, social, and leisure activities.

The Headache Disability Index (HDI) is a 27-item questionnaire. The first two questions asks the patient to identify the frequency (1 per month; more than 1 but less than 4 per month; more than 1 per week) and intensity (mild, moderate, severe) of their headache.

For C&P exams for migraines, the examiner will evaluate whether your migraines are prostrating, so it is important to detail any symptoms or limitations you experience during a migraine episode to ensure the examiner can accurately assess your condition.

At what age did you have your first headache: ___________ What year did your current headaches begin: ___________ ... Does the pain like: â–¡ going from outside - in (compressing, stabbing) â–¡ from inside - out (exploding, pushing out) ... Do your headaches occur on any particular day of the week or time of day?

Answer each question only as it pertains to your headache. SCORING INSTRUCTIONS: Yes = 4 points, Sometimes = 2, No = 0. Using this system, a total score of 10-28 is considered to indicate mild disability; 30-48 is moderate disability; 50-68 is severe disability; 72 or more is complete disability.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232