Pain Survey

Over what proportion of the day do you experience pain?

How well can you perform self-care activities like grooming and dressing?

Describe your walking tolerance?

How many stairs can you climb?

How much leisure time do you spend on the computer each day?

How much time do you spend in quiet meditation or prayer each day?

How much total sleep do you get each night?

How has pain affected your sexual activity?

How well do you walk?

During a typical day, how social are you?

How much do you limit your recreational activity because of chronic pain?

How often do you exercise?

How often do you worry that you are sicker than your doctors, family, and friends realize?

How often does your family react to your pain?

How often do you engage in enjoyable activities?

You believe your best years are?

Compared to your days before chronic pain set in how would you describe your ability to remember things today?

How do you feel about your future?

How often do you think about your pain?

In general, how do you feel?

How often do you use caffeine to get through the day?

During the past four weeks, how often have you felt tense?

Click the submit button below to send me your completed form.

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*This quiz was developed and used with permission by Dr. Peter Abaci. MD, He is an incredible pain specialist who I have had the pleasure of working with.  You can find the quiz in his book Take Charge of Your Chronic Pain. C 2010, pgs 16-20.  To learn more about Dr. Abaci and his approach to managing pain, please visit