Chronic Pain Survey

1. How would you describe your experience with chronic pain during the last 6 months?

 
 
 
 

2. How much has your sleep been affected by chronic pain?

 
 
 
 

3. How much do your thoughts focus on worrying about chronic pain?

 
 
 
 

4. How much do you deal with inflammation overall? Think redness, heat, and swelling. A couple examples include skin issues like eczema or acne, or inflamed joints.

 
 
 
 

5. How is your digestion?

 
 
 
 

6. How do you typically deal with thoughts and emotions that come up for you?

 
 
 
 

7. Do you have a family history of chronic pain conditions, to your knowledge?

 
 
 
 

8. Is your pain getting any better, the same, or worse?

 
 
 
 

9. How much time do you set aside so that you can rest and recuperate?

 
 
 
 

10. How much does chronic pain affect your ability to move around and enjoy physical activity?

 
 
 
 

11. How much does chronic pain affect your ability to feel strong?

 
 
 
 

12. How many areas of chronic pain do you have?

 
 
 
 

13. Fill in the blank. Overall, my health is _____________ :

 
 
 
 

14. How much do believe that your chronic pain can and will improve?