Chronic Pain Assessment 1. Do you experience chronic pain or a chronic illness/disability that substantially decreases your ability to function?(Required) Yes No Unsure 2. How often do you experience pain?(Required) Daily Several times a week Weekly Occasionally 3. What triggers/intensifies your pain? (Select all that apply)(Required) Physical activity Stress Weather changes Lack of sleep Other (Please specify) 4. How do you cope with your pain?(Required) Medication Exercise Physical therapy Support from friends and/or family Not sure 5. How do you cope with stress and/or difficult emotions?(Required) Journaling Meditation Exercise Therapy Not sure 6. Does your chronic pain or chronic illness/disability make you feel isolated?(Required) Yes, no one in my life gets it No, my family and friends do their best to support me I don’t know 7. Do your friends and family give you unhelpful advice such as “If you just got out of the house more, you’d feel better.”?(Required) Yes, if I never hear that again it would be too soon No, but they don’t know what to say either No, they have educated themselves so they don’t say those things 8. Do you feel heard and understood by your medical team?(Required) Yes, they are wonderful No, they disregard everything I say and I need skills to help me during appointments I don’t have a medical team yet and feel overwhelmed by starting the process 9. Are you looking for a therapist that has personal and professional experience with the emotional weight of chronic pain and/or disability?(Required) Yes, why else would I be taking this quiz Yes, let’s get started No, I’m not ready for yet another appointment Enter your Name(Required) Email(Required)
