LTE DAILY HEADACHE SELF-MONITORING FORM DIRECTIONS: Four tines each day, please rat yourheadache intensity, disability level, and stress wsing the rating scales below. Mark the tines that you were sleeping and eating by coloring (or putting ) in the boxes. You may indicate % hour increments by coloring of 2 tox (or we slash). Also record body temperature, whether menstruating and ratings ct sleep amount and sleep qualiy. HEADACHE INTENSITY DISABILITY ‘STRESS 12 BITREUELYPANFUL yma nsemesoaiante || 1 COMPLETE MPARED(2esmg | 10 EXTREMELY 8 VERT PANEU yr an eran ‘AMOUNT * . 7 ? © Paver. prion pt ne lcnctn || & MODERATELY MPARED ‘ 4 MROLYPARFUL....jemigunmybatcra mente imel] 4 MLOLY PAIRED “ 2 3 3 2 SUGHTLY PAINFUL ty nace maa steritecam| 2 MNMALLYMARED 2 © NOMADIC 0 NowPARMENT ° (WEEKLY MEDICATION LIST (AND AMOUNT): 20% 4 % 0 10 Ww ¥ word) ‘MONDAY