To complete this survey, please just copy to your word processor, complete the survey and then repost it. Answering the following questions is 100% up to you the pain patient. All surveys are done and turned in with no names attached. Your name or any personal contact information you put on the survey will “NEVER” be handed out.
1) What is your age group?
A) 20 – 30
B) 31 – 40
C) 40 – 50
D) 51 – 70
E) 71 – Older
2) Male [ ]
Female [ ]
3) How long have you been living with your pain?
A) Under a year
B) 1-5 years
C) 6-10 years
D) 11-15 years
E) Over 15 years
4) What is your current pain level?
1. 😀 No pain 8. 😥 Withdrawn pain
2. 😏 Some pain 9. 😣 Killer pain
3. 😒 Bothersome 10. 😳 Thrashing pain
4. 😣 Hurts 11. 😬 Hey dude WTF
5. 😔 Dr Visit 12. 😤 Do anything
6. ☹️ Radiating pain 13. 😖 Pills or Die
7. 😕 Miserable 14. 🤬 I dare U asshat
15. 🤯 Tell me to take Tylenol again.
I’ll kill you and hide the body.
5) In what area of the U.S. do you live?
D) Middle U.S. North
E) Middle U.S. South
G) South East
H) Other ________________
6) How far do you have to travel for Pain Management?
7) When is your pain at its worst?
A) Morning B) Mid-Day C) Evening D) Night
8) Were you were tapered off your opioids? was it voluntary or involuntary. What was the length of your taper period (# days, weeks, months).
9) How long have you been on opioid based medications without any problems?
10) Has your Pain Management clinic had to close?
11) How far do you have to travel to see your pain management doctor?
A) 1-25 miles
B) 26-59 miles
C) 50-75 miles
D) 76-100 miles
E) 100-150 miles
F) 151 miles plus
12) Have you ever been denied getting your prescriptions filled?
YES [ ]
NO [ ]
13) If yes, at what pharmacies? ___________________________
14) Have you lost all access to narcotic pain medication?
15) Please provide a brief background about your condition? What caused
your issue? ___________________________________
16) On a scale of 1-10 (worst -best), what is your current pain without
medications? ________ With medications? __________
17) Have you tried non-prescribed types of relief?
C) CBD Oil
D) Other? _________________
18) Are you currently seeing a Pain Management Doctor (PMD) or your primary
care physician (PCP)? If your seeing a PMP, did you request it or did your PCP?
A) PCP Requested (___________)
B) I requested it (___________)
19) What medical related products are you using to help control
A) Prescription Medication
B) Herbs or other form of treatment
C) Medical Device (Please describe your product, & who the
manufacturer is as well as if you think it helps).
20) Are you still working?
A) Full Time (_____)
B) Part Time (_____)
C) From Home (_____)
D) Not Working
21) Rate your doctor on how well you feel he listens to you? (1 “Least – 5 sometimes – 10 Best”)
22) Do you feel your pain management doctor has your best interest in mind?
23) Is your pain management doctor compassionate? (1 “Least – 5 sometimes – 10 Best”)
24) How do you get them to understand you have done everything in your power at home to relive your pain the best way you can before even asking if more meds will help?
25) Do you think your pain management doctor listens? (1 “Least – 5 sometimes – 10 Best”)
26) Is your pain level higher during or after any given activity,
27) How do you cope with walking? ______________________
28) Do you use aids other than a cane, crutch, wheelchair? i.e. shopping cart, counters, shelves ?
29) Does eating lessen your pain?
30) Please describe your pain.
31) Have you ever been addicted to any of the medications your Pain
Management Doctor has prescribed for you?
32) What one thing do you want people to most about chronic pain?
33) Has anything ever truly helped reduce your pain? If so, what was it?
34) Since the CDC Guidelines came out, has you Pain Management Doctor,
A) Reduced your pain medication?
B) Stopped your pain medications?
C) Reduced your pumps flow rate or cancelled your Bolus doses?
D) How did this affect your treatment or future medications?
35) With the CDC Guidelines how else has your pain management treatment been affected?
36) Does having chronic pain and being on a long term opioid treatment negatively impacted
your ability to get even primary care?
37) With the CDC’s urine test requirements, have you ever tested as a false positive?
38) How did this affect your treatment or future medications?
39) What do you do to cope, ie distraction, eating, chocolate?
40) How much does it effect your daily life /mobility /activity/ sex/ depression, etc.?
41) How do you fake not showing pain when at a function or family event?
42) How many days are you down after completing a small activity, med activity and large activity?
43) When you are hanging on to your rope by the very end knot how do you calm yourself?
44) Other then medications, what have you tried to help calm your pain? i.e. yoga, meditation, etc.
45) How do you explain your pain so the doctors understand it without thinking ur just looking for more meds?
46) What things can you do now that you couldn’t do before the pump?
47) Has your sex life been affected either by the drugs themselves, your pain or by the physical location of your pump?
48) One word to describe how having to rely on a pain pump makes you feel inside?
49) Was this, or is this your last option in controlling some or all of your pain or is this a choice you’ve made?
50) Thank you for participating in the, “2019′ Chronic Pain Survey By Chronic Pain Patients.”