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Chronic Pain Intake

Chronic Pain Intake

  • Please enter a number from 5 to 120.
  • 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 confident

  • Please enter a number from 0 to 5.
  • Please enter a number from 0 to 5.
  • Please enter a number from 0 to 5.
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  • Please enter a number from 0 to 5.
  • Please enter a number from 0 to 5.
  • Please enter a number from 0 to 5.
  • Please enter a number from 0 to 5.
  • Please enter a number from 0 to 5.
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  • Please enter a number from 0 to 5.
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  • Please enter a number from 0 to 5.
  • Please enter a number from 0 to 5.
  • Please enter a number from 0 to 7.
  • Please enter a number from 0 to 10.
    0 = No pain 10 = Worst imaginable pain
  • On a scale of 0 - 5 with 0 = not at all hopeful, and 5 = very hopeful

  • Please enter a number from 0 to 5.
  • Please enter a number from 0 to 5.
  • Please enter a number from 0 to 5.

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