| RPT |
|Migraine Disability Assessment Test (MIDAS)
| Gender: <.Patient_Gender.>
|
|<*Answer_7771*>
|
|
|Questions and Answers:
|
| 1. On how many days in the last 3 months did you miss work or school
| because of your headaches?
| <*Answer_8947*>
|
| 2. How many days in the last 3 months was your productivity at work or
| school reduced by half or more because of your headaches? (Do not
| include days you counted in question 1 where you missed work or
| school.)
| <*Answer_8948*>
| 3. On how many days in the last 3 months did you not do household work
| (such as housework, home repairs and maintenance, shopping, caring
| for children and relatives) because of your headaches?
| <*Answer_8949*>
| 4. How many days in the last 3 months was your productivity in household
| Date Given: <.Date_Given.>
| work reduced by half of more because of your headaches? (Do not
| include days you counted in question 3 where you did not do household
| work.)
| <*Answer_8950*>
| 5. On how many days in the last 3 months did you miss family, social or
| leisure activities because of your headaches?
| <*Answer_8951*>
|
| A. On how many days in the last 3 months did you have a headache? (If a
| headache lasted more than 1 day, count each day.)
| Clinician: <.Staff_Ordered_By.>
| <*Answer_8952*>
| B. On a scale of 0 - 10, on average how painful were these headaches?
| (where 0=no pain at all, and 10=pain as bad as it can be.)
| <*Answer_8953*>
|
|Information contained in this note is based on a self-report assessment
|and is not sufficient to use alone for diagnostic purposes. Assessment
|results should be verified for accuracy and used in conjunction with
|other diagnostic activities.
||(c) Innovative Medical Research 1997
| Location: <.Location.>
|(c) 2007, AstraZeneca Pharmaceuticals, LP. All Rights reserved.
|
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
