Chronic Pain Assessment Form
There are 4 necessary steps and most of us overlook at least one of them. Use this assessment to find out which step you’ve missed, possibly without even realizing it.

(13 Multiple Choice Questions, Estimated Time Required = 4 minutes)
Email address *
First Name *
Last Name *
Gender *
Age *
What describes your current body? *
What have you tried in the past to reduce your pain? *
What sort of results have you achieved in the past? *
How many alcoholic drinks do you drink per week? *
How much stress do you experience during a typical day? *
How many hours do you sleep a night? *
How many times per week do you exercise? *
When you exercise, how hard do you push yourself? *
How often do you think about your weight and how it affects your health? *
What would your ideal goal be for next month? *
How much would your life change if you didn't have chronic pain? *
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