California Headache & Balance Center

<%@LANGUAGE="JAVASCRIPT"%><% // *** Insert Record: construct a sql insert statement and execute it var MM_editAction = Request.ServerVariables("URL") + '?' + Request.QueryString; if (String(Request("MM_insert")) != "undefined") { var MM_tableName = "Email"; var MM_fields = "txtEmail,Email,',none,''"; var MM_redirectPage = ""; // create the insert sql statement var MM_tableValues = "", MM_dbValues = ""; var MM_fieldsArray = MM_fields.split(","); for (var i=0; i+4 < MM_fieldsArray.length; i+=5) { var formVal = String(Request.Form(MM_fieldsArray[i])); var delim = (MM_fieldsArray[i+2] != "none") ? MM_fieldsArray[i+2] : ""; var altVal = (MM_fieldsArray[i+3] != "none") ? MM_fieldsArray[i+3] : ""; var emptyVal = (MM_fieldsArray[i+4] != "none") ? MM_fieldsArray[i+4] : ""; if (formVal == "" || formVal == "undefined") { formVal = emptyVal; } else { if (altVal != "") { formVal = altVal; } else if (delim == "'") { // escape quotes formVal = "'" + formVal.replace(/'/g,"''") + "'"; } else { formVal = delim + formVal + delim; } } MM_tableValues += ((i != 0) ? "," : "") + MM_fieldsArray[i+1]; MM_dbValues += ((i != 0) ? "," : "") + formVal; } var MM_insertStr = 'insert into ' + MM_tableName + ' (' + MM_tableValues + ') values (' + MM_dbValues + ')'; // finish the sql and execute it var MM_insertCmd = Server.CreateObject("ADODB.Command"); MM_insertCmd.ActiveConnection = "dsn=balance;"; MM_insertCmd.CommandText = MM_insertStr; MM_insertCmd.Execute(); // redirect with URL parameters if (MM_redirectPage == '') MM_redirectPage = Request.ServerVariables('URL'); if (String(MM_redirectPage).indexOf('?') == -1) MM_redirectPage += '?' + Request.QueryString; Response.Redirect(MM_redirectPage); } %> California Headache & Balance Center

The MIDAS questionnaire, otherwise known as the 'Migraine Disability Assessment Questionnaire', is a questionnaire developed to help physicians and patients assess headaches so that the proper treatment can be rendered correctly. It measures disability that is caused by headaches by counting the number of days lost as a result of headaches.

This questionnaire was developed by Professor Richard Lipton of the Albert Einstein College of Medicine in New York and Dr. Walter Steward of the Johns Hopkins School of Public Health in Baltimore. For more information on the MIDAS questionnaire, please visit the MIDAS website.

Please answer the all of the following questions regarding your headaches. After completing the questionnaire, please note the total at the bottom. This total is used to measure the grade of your headaches, as determined by your disability level. Please refer to the legend at the bottom of the table for grade information.

Migraine Disability Assessment Questionnaire

1. How many days of work or school did you miss in the last 3 months due to your headaches?

day(s)

2. How many days in the last 3 months was your productivity at work or school reduced by half or more due to your headaches? (Please do not include days you counted in question 1 where you missed work or school)

day(s)

3. On how many days in the last 3 months did you not do household work because of your headaches?

day(s)

4. How many days in the last 3 months was your productivity in household work reduced by half or more because of your headaches? (Do not include days you counted in question 3 where you did not do household work)

day(s)

5. On how many days in the last 3 months did you miss family, social or leisure activities because of your headaches?

day(s)

Your Rating:

Total:

day(s)

Grade	Definition	Score

I	Minimal or infrequent disability	0-5

II	Mild or infrequent disability	6-10

III	Moderate disability	11-20

IV	Severe disability	21+

Fresno Headache & Balance Center


	MIDAS Headache Rating Scale
	How severe are your headaches? Are they disabling? Take the MIDAS Headache Rating Scale and assess the severity of your headahces.

	Headache Types
	Migraine headache Migraine in pregnancy Episodic tension-type Chronic tension-type Chronic daily headache Trigeminal neuralgia Cervical headache Cluster headache Paroxysmal hemicranea Rebound headache Organic headache