Chronic Pain Quiz

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* 1. How long have you experienced pain?

1 month or less

3 months

6 months or more

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* 2. What is your average level of pain?

1: My pain is hardly noticeable. Most of the time I am not distracted by my pain.

5: Distracting. I am preoccupied with my pain most of the time. With effort, I can continue most of my daily activities.

10: Unmanageable. My pain is all I think about. I can barely move. I often cry due to my pain.

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 3. How has your pain affected your ability to do the things you love?

Not at all

Some: I can do my regular daily activities, but, I can't do some things I used to enjoy.

A lot: I can't do my regular daily activities without pain.

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* 4. Where is your pain located?

Neck

Shoulder(s)

Upper back

Lower back

Hip(s)

Buttock(s)

Leg(s)

Knee(s)

Foot/feet

Other (please specify)

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* 5. Who have you talked to about your pain?

No one

Friends and family

My Primary Care Provider

A Surgeon

A Pain Specialist

Other (please specify)

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* 6. Which of the following treatment options have you tried for your pain?

Stretching, exercise, yoga

Physical therapy

Massage, chiropractor

Pain Medication

Steroid injection

Epidural

Nerve block

Radiofrequency ablation

Pain pump implant

Transcutaneous electrical nerve stimulation (TENS)

Spinal cord stimulator

None of the above

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* 7. How old are you?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 8. Are you interested in learning how the University Center for Pain Management can help you or your loved one with chronic pain?

Yes

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* 9. Please leave your contact information and someone from our staff will give you a call to discuss how you can become a patient of UCPMK. Thank you!

Name

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Chronic Pain Quiz

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* 1. How long have you experienced pain?

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* 2. What is your average level of pain?

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* 3. How has your pain affected your ability to do the things you love?

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* 4. Where is your pain located?

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* 5. Who have you talked to about your pain?

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* 6. Which of the following treatment options have you tried for your pain?

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* 7. How old are you?

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* 8. Are you interested in learning how the University Center for Pain Management can help you or your loved one with chronic pain?

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* 9. Please leave your contact information and someone from our staff will give you a call to discuss how you can become a patient of UCPMK. Thank you!

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