Applicant Survey for Chronic Pain Research Pilot
Dear Applicant

Thank you for your interest in participating in the Chronic Pain Research Pilot. Please answer the questions below to the best of your knowledge. A member of the research team will contact you upon review of the information submitted. Thank you.
Given Name *
Surname *
Phone Number *
Email
Have you ever heard of the following healing modalities? Please check all appropriate boxes. *
Required
Please describe your pain level using a scale from 1 (no pain) to 5 (extreme pain). *
1: no pain
2: little pain
3: medium pain
4: severe pain
5: extreme pain
My current pain is
During the past week, my average pain has been
During the past three months, my average pain has been
Is being touched on your neck, back or spine painful for you?
Is laying on your stomach for 50 minutes painful for you? *
Can you be available for one (1) treatment every week between 24 March 2020 and 17 May 2020 for a total of 7 consecutive treatments? *
What days and times are you available?
09.00am - 12.00pm
12.00pm - 5.00pm
5.00pm - 8.00pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What is your age range? *
Thank you!
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