BOTOX Treatment for. Botulinum Toxin Type A. Chronic Migraine Patient Diary

Transcription

1 BOTOX Treatment for Chronic Migraine Patient Diary

2 HIT-6 Headache Impact Test Instructions for Patient Diary This questionnaire was designed to help you describe and communicate the way you feel and what you cannot do because of headaches. To complete, please circle one answer for each question. 1 When you have headaches, how often is the pain severe? Total How often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities? When you have a headache, how often do you wish you could lie down? In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches? In the past 4 weeks, how often have you felt fed up or irritated because of your headaches? In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities? (6 points each) (8 points each) (10 points each) (11 points each) (13 points each) Your doctor has asked you to fill in this 24 week diary to understand how your BOTOX treatment is helping you manage your chronic migraine. Please follow the directions below when filling in your diary: Start filling in the diary after your first treatment and make an appointment to visit your specialist again in 12 weeks. Write the date in the space provided (e.g. 20/8 to indicate the 20th of August) Answer the questions by ticking the boxes & writing the names of the medications you take each day. If you did NOT experience a headache on any specific day, please leave the boxes blank and just fill in the medications that you have taken (if any). Bring this diary with you to your next appointment (12 weeks after your first injection). After your second BOTOX treatment please fill out the remaining 12 weeks. At your follow-up appointment (12 weeks after your second treatment) your doctor will reassess your condition and advise you about continuing treatment. To score, add points for answers in each column. TOTAL SCORE: Please share your HIT-6 results with your doctor

3 BOTOX Chronic Migraine Patient Diary Date of Injection: Week Week 4 5 6

4 BOTOX Chronic Migraine Patient Diary Week Week

5 HIT-6 Headache Impact Test Additional Notes 12 week assessment Date completed: 1 When you have headaches, how often is the pain severe? Total How often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities? When you have a headache, how often do you wish you could lie down? In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches? In the past 4 weeks, how often have you felt fed up or irritated because of your headaches? In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities? (6 points each) (8 points each) (10 points each) (11 points each) (13 points each) To score, add points for answers in each column. TOTAL SCORE: Please share your HIT-6 results with your doctor

6 BOTOX Chronic Migraine Patient Diary Date of second treatment: Week Week

7 BOTOX Chronic Migraine Patient Diary Date of second treatment: Week Week

8 HIT-6 Headache Impact Test Additional Notes 24 week assessment Date completed: 1 When you have headaches, how often is the pain severe? Total How often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities? When you have a headache, how often do you wish you could lie down? In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches? In the past 4 weeks, how often have you felt fed up or irritated because of your headaches? In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities? (6 points each) (8 points each) (10 points each) (11 points each) (13 points each) To score, add points for answers in each column. TOTAL SCORE: Please share your HIT-6 results with your doctor

9 BOTOX is a registered trademark of Allergan Inc. Allergan Australia Pty Ltd 810 Pacific Highway Gordon NSW 2072 ABN AU/0127/2011