I have always wanted to do a survey of other chronic pain/pain individuals ever since my second psychology class. The reason I would like to do this is to help try and find what can be done to help other with their pain in a more effective way. This survey is the collection of all the questions I have been ask over the past 21 years of seeing doctors or being admitted. This survey is for you, your caree, family or friends. I would appreciate if you could complete this for you or your caree (even both is OK) and return it to me when possible. I am going to allow 6 weeks for this to be completed and returned and then allow myself three weeks to compile the results. If you may have any questions feel free to send me an email, every email received will receive a reply.
Here’s hoping you find out something about yourself when completing this.
PAIN SURVEY FORM
Conducted By: PickYourPain.org, Richard K.
Name/ID: _______________________________________ Today’s Date: _______________
(Real Name Not Required, Use a Screen Name or Other)
Age:1 -17 ( ) 18 – 25 ( ) 26 – 35 ( ) 36 – 45 ( ) 46 – 55 ( ) 56 – 65 ( ) 66 + ( )
What is Your Location (City, State): _________________________________________ Date Pain Started: ____________
What is location of pain:Head ( )Arms ( )Body ( )Legs ( )Back ( )Other ( )_______
What is the average intensity of your pain? (0 “No Pain” – 10 “Major”) _________
What is the least and worst level of pain you have? (See Above Scale) ________
How would you describe your pain? Constant: _____ Throbbing: _____ Electrical Stabbing: _____
When is your pain at it’s worst? Morning: _____ Mid-Day: _____ Evening: _____ Other: _____ Set: _____
When is your pain at it’s best? Morning: _____ Mid-Day: _____ Evening: _____ Other: _____ Set: _____
Explain the location of your pain? ______________________________________________________________________________________________
What was the cause of your pain? __________________________________________________________________________________________
What is Prescribed to Control the Pain?: ______________________________________________________________________________________
What have you tried for pain? (other than listed above): _________________________________________________________________________
What have you found works best to reduce/illuminate your pain? __________________________________________________________________
How much sleep do you get? (On Average) ____________________
How many times are you awake at night due to the pain? _____
How often does your pain affect you during the day? __________
For how long do your pain episodes last? _____________________
Have you tried anything “not prescribed” by your doctor? (Eastern Medicine, Braces, etc.) _____________________________________________
Have you researched your pain on the internet? ___________________________
Any sites you would recommend? _________________________________________
Anything else we did not ask you about that you feel we should have? ______________________________________________________________
What were your thoughts about the survey? ___________________________________________________________________________________
If you would like to receive a copy of this information please leave the email address you would like this to go to below. Only those who supply an email will receive this information.
“NO” personal information will be shared for anyone or for any reason, period.
PickYourPain.org Richard (@kreisr1) is a Tri-Fecta caregiver. He cares for his mother with heart and lung issues, co-cares for his brother in-law who lives with him and his wife and is dealing with epilepsy and is himself a 21 year patient suffering from chronic back pain. Richard blogs about the issues of having chronic pain and those he runs into in the health care system and how to deal with them using humor on his site, PickYourPain.org, Caregiving.com and InTake.Me where he works with caregivers through support groups and internet radio. He performs real world testing of related products and is doing research into pain in general. Richard’s tag line is “Pain without Humor is just Painful.
The contents of this web site are for informational purposes only. PickYourPain.org does not endorse or recommend any unrelated organization that may be referenced in this site. This site is not intended to furnish medical advice to anyone. Any diagnosis, treatment or care of a patient should be discussed with a physician. Our survey collects information that is aggregated and used internally to develop applications and services that better meet your needs. Individually identifiable information entered on the survey is used internally for purposes of this survey and will never be provided to third parties at all, for any reason.Note:We here at PickYourPain.org would like to thank you in advance for participating in this survey. All data received will be forwarded to any participant involved via email “only.” If you are interested please insert your email address below. Please insert your email on the line above
The information here is going to be utilized to work up an app that allow all of this to be tracked via standard smartphones. Thank you in advance for taking the time to look at, complete and return the “Pain Survey Form,” Conducted By: PickYourPain.org, Richard K., PickYourPain@att.net