CSI Survey

Question Title

* 1. Client Name: Surname, First Name

Question Title

* 2. Part A: Please circle the best response to the right of each statement.

	0 Never	1 Rarely	2 Sometimes	3 Often	4 Always
I feel tired and unrefreshed when I wake from sleeping	I feel tired and unrefreshed when I wake from sleeping 0 Never	I feel tired and unrefreshed when I wake from sleeping 1 Rarely	I feel tired and unrefreshed when I wake from sleeping 2 Sometimes	I feel tired and unrefreshed when I wake from sleeping 3 Often	I feel tired and unrefreshed when I wake from sleeping 4 Always
My muscles feel stiff and achy	My muscles feel stiff and achy 0 Never	My muscles feel stiff and achy 1 Rarely	My muscles feel stiff and achy 2 Sometimes	My muscles feel stiff and achy 3 Often	My muscles feel stiff and achy 4 Always
I have anxiety attacks	I have anxiety attacks 0 Never	I have anxiety attacks 1 Rarely	I have anxiety attacks 2 Sometimes	I have anxiety attacks 3 Often	I have anxiety attacks 4 Always
I grind or clench my teeth	I grind or clench my teeth 0 Never	I grind or clench my teeth 1 Rarely	I grind or clench my teeth 2 Sometimes	I grind or clench my teeth 3 Often	I grind or clench my teeth 4 Always
I have problems with diarrhea and/or constipation	I have problems with diarrhea and/or constipation 0 Never	I have problems with diarrhea and/or constipation 1 Rarely	I have problems with diarrhea and/or constipation 2 Sometimes	I have problems with diarrhea and/or constipation 3 Often	I have problems with diarrhea and/or constipation 4 Always
I need help in performing my daily activities	I need help in performing my daily activities 0 Never	I need help in performing my daily activities 1 Rarely	I need help in performing my daily activities 2 Sometimes	I need help in performing my daily activities 3 Often	I need help in performing my daily activities 4 Always
I am sensitive to bright lights	I am sensitive to bright lights 0 Never	I am sensitive to bright lights 1 Rarely	I am sensitive to bright lights 2 Sometimes	I am sensitive to bright lights 3 Often	I am sensitive to bright lights 4 Always
I get tired very easily when I am physically active	I get tired very easily when I am physically active 0 Never	I get tired very easily when I am physically active 1 Rarely	I get tired very easily when I am physically active 2 Sometimes	I get tired very easily when I am physically active 3 Often	I get tired very easily when I am physically active 4 Always
I feel pain all over my body	I feel pain all over my body 0 Never	I feel pain all over my body 1 Rarely	I feel pain all over my body 2 Sometimes	I feel pain all over my body 3 Often	I feel pain all over my body 4 Always
I have headaches	I have headaches 0 Never	I have headaches 1 Rarely	I have headaches 2 Sometimes	I have headaches 3 Often	I have headaches 4 Always
I feel discomfort in my bladder and/ or burning when I urinate	I feel discomfort in my bladder and/ or burning when I urinate 0 Never	I feel discomfort in my bladder and/ or burning when I urinate 1 Rarely	I feel discomfort in my bladder and/ or burning when I urinate 2 Sometimes	I feel discomfort in my bladder and/ or burning when I urinate 3 Often	I feel discomfort in my bladder and/ or burning when I urinate 4 Always
I do not sleep well	I do not sleep well 0 Never	I do not sleep well 1 Rarely	I do not sleep well 2 Sometimes	I do not sleep well 3 Often	I do not sleep well 4 Always
I have difficulty concentrating	I have difficulty concentrating 0 Never	I have difficulty concentrating 1 Rarely	I have difficulty concentrating 2 Sometimes	I have difficulty concentrating 3 Often	I have difficulty concentrating 4 Always
I have skin problems such as dryness, itchiness, or rashes	I have skin problems such as dryness, itchiness, or rashes 0 Never	I have skin problems such as dryness, itchiness, or rashes 1 Rarely	I have skin problems such as dryness, itchiness, or rashes 2 Sometimes	I have skin problems such as dryness, itchiness, or rashes 3 Often	I have skin problems such as dryness, itchiness, or rashes 4 Always
Stress makes my physical symptoms get worse	Stress makes my physical symptoms get worse 0 Never	Stress makes my physical symptoms get worse 1 Rarely	Stress makes my physical symptoms get worse 2 Sometimes	Stress makes my physical symptoms get worse 3 Often	Stress makes my physical symptoms get worse 4 Always
I feel sad or depressed	I feel sad or depressed 0 Never	I feel sad or depressed 1 Rarely	I feel sad or depressed 2 Sometimes	I feel sad or depressed 3 Often	I feel sad or depressed 4 Always
I have low energy	I have low energy 0 Never	I have low energy 1 Rarely	I have low energy 2 Sometimes	I have low energy 3 Often	I have low energy 4 Always
I have muscle tension in my neck and shoulders	I have muscle tension in my neck and shoulders 0 Never	I have muscle tension in my neck and shoulders 1 Rarely	I have muscle tension in my neck and shoulders 2 Sometimes	I have muscle tension in my neck and shoulders 3 Often	I have muscle tension in my neck and shoulders 4 Always
I have pain in my jaw	I have pain in my jaw 0 Never	I have pain in my jaw 1 Rarely	I have pain in my jaw 2 Sometimes	I have pain in my jaw 3 Often	I have pain in my jaw 4 Always
Certain smells, such as perfumes, make me feel dizzy and nauseated	Certain smells, such as perfumes, make me feel dizzy and nauseated 0 Never	Certain smells, such as perfumes, make me feel dizzy and nauseated 1 Rarely	Certain smells, such as perfumes, make me feel dizzy and nauseated 2 Sometimes	Certain smells, such as perfumes, make me feel dizzy and nauseated 3 Often	Certain smells, such as perfumes, make me feel dizzy and nauseated 4 Always
I have to urinate frequently	I have to urinate frequently 0 Never	I have to urinate frequently 1 Rarely	I have to urinate frequently 2 Sometimes	I have to urinate frequently 3 Often	I have to urinate frequently 4 Always
My legs feel uncomfortable and restless when I am trying to go to sleep at night	My legs feel uncomfortable and restless when I am trying to go to sleep at night 0 Never	My legs feel uncomfortable and restless when I am trying to go to sleep at night 1 Rarely	My legs feel uncomfortable and restless when I am trying to go to sleep at night 2 Sometimes	My legs feel uncomfortable and restless when I am trying to go to sleep at night 3 Often	My legs feel uncomfortable and restless when I am trying to go to sleep at night 4 Always
I have difficulty remembering things	I have difficulty remembering things 0 Never	I have difficulty remembering things 1 Rarely	I have difficulty remembering things 2 Sometimes	I have difficulty remembering things 3 Often	I have difficulty remembering things 4 Always
I suffered trauma as a child	I suffered trauma as a child 0 Never	I suffered trauma as a child 1 Rarely	I suffered trauma as a child 2 Sometimes	I suffered trauma as a child 3 Often	I suffered trauma as a child 4 Always
I have pain in my pelvic area	I have pain in my pelvic area 0 Never	I have pain in my pelvic area 1 Rarely	I have pain in my pelvic area 2 Sometimes	I have pain in my pelvic area 3 Often	I have pain in my pelvic area 4 Always

Question Title

* 3. Interpretation of scores (for office use only)

TOTAL SCORE: add up the total scores = _______
Score Range: Subclinical: 0 to 29, Mild: 30 to 39, Moderate: 40 to 49, Severe: 50 to 59, Extreme: 60 to 100

Question Title

* 4. Part B: Have you been diagnosed by a doctor with any of the following?

	Yes	No
Restless Leg Syndrome	Restless Leg Syndrome Yes	Restless Leg Syndrome No
Chronic Fatigue Syndroms	Chronic Fatigue Syndroms Yes	Chronic Fatigue Syndroms No
Fibromyalgia	Fibromyalgia Yes	Fibromyalgia No
Temporomandibular Joint Disorder	Temporomandibular Joint Disorder Yes	Temporomandibular Joint Disorder No
Migraine or tension headaches	Migraine or tension headaches Yes	Migraine or tension headaches No
Irritable Bowel Syndrome	Irritable Bowel Syndrome Yes	Irritable Bowel Syndrome No
Multiple Chemical Sensitivities	Multiple Chemical Sensitivities Yes	Multiple Chemical Sensitivities No
Neck Injury (including whiplash)	Neck Injury (including whiplash) Yes	Neck Injury (including whiplash) No
Anxiety or Panic Attacks	Anxiety or Panic Attacks Yes	Anxiety or Panic Attacks No
Depression	Depression Yes	Depression No

This questionnaire is taken from: Scerbo T, Colasurdo J, Dunn S, Unger J, Nijs J, Cook C. Measurement properties of the central sensitization inventory: a systematic review. Pain Practice. 2018 Apr;18(4):544-54.

Question Title

* 1. Client Name: Surname, First Name

Question Title

* 2. Part A: Please circle the best response to the right of each statement.

Question Title

* 3. Interpretation of scores (for office use only)TOTAL SCORE: add up the total scores = _______ Score Range: Subclinical: 0 to 29, Mild: 30 to 39, Moderate: 40 to 49, Severe: 50 to 59, Extreme: 60 to 100

Question Title

* 4. Part B: Have you been diagnosed by a doctor with any of the following?

* 3. Interpretation of scores (for office use only)

TOTAL SCORE: add up the total scores = _______
Score Range: Subclinical: 0 to 29, Mild: 30 to 39, Moderate: 40 to 49, Severe: 50 to 59, Extreme: 60 to 100