Chronic Pain Intake Chronic Pain Intake Name First Last PhoneEmail Emergency Contact*Age*Please enter a number from 5 to 120.GenderAre you a veteran?*YesNoHow did your main pain begin?*Injury at homeInjury at work/schoolInjury in other settingMotor vehicle accidentCancerMedical condition other than cancerAfter surgeryNo obvious causeHow long has your main pain been present?*Less than 3 months3 - 12 months12 months - 2 years2 - 5 yearsMore than 5 yearsWhat statement best describes your pain?*Always present with the same intensityAlways present with varying levelsOften present (pain-free periods last less than 6 hours)Occasionally present (pain occurs once to several times per day, lasting up to an hour)Rarely present (pain occurs every few days or weeks)Please rate how confident you are that you can do the following things at present despite the pain using a scale of 0 - 5 with 0 = Not at all confident, and 5 = Completely confidentI can enjoy things, despite the pain.*Please enter a number from 0 to 5.I can do most of the household chores.*Please enter a number from 0 to 5.I can do errands and shopping.*Please enter a number from 0 to 5.I can socialize with my friends and family members as often as I want to.*Please enter a number from 0 to 5.I can cope with my pain in most situations.*Please enter a number from 0 to 5.I can do some form of work, despite the pain.*Please enter a number from 0 to 5.I can still do many of the things I enjoy doing, such as hobbies or leisure activities.*Please enter a number from 0 to 5.I can cope with my pain without medication.*Please enter a number from 0 to 5.I can still accomplish most of my goals in life.*Please enter a number from 0 to 5.I can live a normal lifestyle.*Please enter a number from 0 to 5.I can sleep well and wake feeling refreshed.*Please enter a number from 0 to 5.I can gradually become more active.*Please enter a number from 0 to 5.I can easily get down on the ground.*Please enter a number from 0 to 5.I can easily get up from the ground.*Please enter a number from 0 to 5.I can easily climb stairs.*Please enter a number from 0 to 5.I can go for a walk of 15 minutes.*Please enter a number from 0 to 5.In what part(s) of your body do you experience persistent or recurring pain?How many days per week does pain interfere with your day-to-day activities?*Please enter a number from 0 to 7.In the past 7 days, how would you rate your pain on average?Please enter a number from 0 to 10.0 = No pain 10 = Worst imaginable painWhen is your pain worse? Morning Daytime Evening Night When is your pain better? Morning Daytime Evening Night Do you think you should limit your activities when you have pain?*YesNoWhat would you like to get out of this program? (What is the primary issue you would like to resolve?)Do you have experience with Yoga? Alexander Technique? Mindfulness? Tai chi?YesNoWhat activities do you wish to return to / be able to do?*What is your biggest challenge right now?What are your strengths that will help you move through this challenge?What brings you joy?What’s the thing that helps most with your pain?On a scale of 0 - 5 with 0 = not at all hopeful, and 5 = very hopefulHow hopeful are you of being able to lower your pain?*Please enter a number from 0 to 5.How hopeful are you of being able to recover from pain?*Please enter a number from 0 to 5.How hopeful are you of being able to resume your activities?*Please enter a number from 0 to 5.3 months from now we will ask you to fill out a follow-up survey. Would you be willing to do a follow-up survey?*YesNoOther past or current medical conditions your teacher should know about
