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Power of Pain, Community Needs Assessment Survey
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1. Have you received care from a pain management provider for Chronic Pain in the last 6 months
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2. Have you received care from a primary care physician (PCP) for chronic pain issues in the last 6 months?
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3. Which type of provider treats your chronic pain most often
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4. How long have you been going to your primary treating provider for chronic pain?
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5. What type of activites do you feel will increase your ability to communicate with providers
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6. In the last 12 months, how many times did you visit your healthcare provider?
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7. In the last 12 months, did you phone your healthcare provider’s office to get an appointment for an illness, injury, or condition that needed care right away?
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8. In the last 12 months, when you phoned your pain care provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?
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9. In the last 12 months, did you make any appointments for a check-up or routine care with your healthcare provider?
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10. In the last 12 months, when you made an appointment for a check-up or routine care with your healthcare provider, how often did you get an appointment as soon as you needed?
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11. Symptoms experienced in the past 6 months or more
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12. In the last 12 months, did you phone your healthcare provider’s office with a medical question regarding your pain condition during regular office hours?
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13. In the last 12 months, when you phoned your healthcare provider’s office during regular office hours, how often did you get an answer to your medical question that same day?
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14. In the last 12 months, did you phone your healthcare provider’s office with a medical question after regular office hours?
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15. In the last 12 months, when you phoned your healthcare provider’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed?
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16. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see your healthcare provider within 15 minutes of your appointment time?
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17. In the last 12 months, how often did your healthcare provider explain things in a way that was easy to understand?
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18. Age of onset of Chronic Pain Symptoms/Disease
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19. Age at diagnosis
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20. What is your age?
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21. Family History of Chronic Pain?
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22. How long have you been living with chronic pain?
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22. In the last 12 months, how often did your healthcare provider seem to know the important information about your medical history?
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23. I have been diagnosed with a chronic pain disease involving?
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24. In the last 12 months, how often did your healthcare provider show respect for what you had to say?
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25. In the last 12 months, how often did your healthcare provider spend enough time with you?
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26. In the last 12 months, how often did your healthcare provider give you easy to understand information about these health questions or concerns?
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27. What is your ethnic background?
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28. What is the highest grade or level of school that you have completed?
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29. Are you male or female
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30. In the last 12 months, how often did your healthcare provider listen carefully to you?
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31. In general, how would you rate your overall mental/emotional health?
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32. In general, how would you rate your overall physical health?
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33. In the last 12 months, how often did clerks and receptionists at your healthcare provider's office treat you with courtesy and respect?
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34. In the last 12 months, how often were clerks and receptionists at your healthcare provider's office as helpful as you thought they should be?
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35. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate your healthcare provider?
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36. In the last 12 months, did your healthcare provider order a blood test, x-ray, or other test for you?
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37. In the last 12 months, when your healthcare provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?
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