Teleconference Name * Phone Number Date * Email Address * Please rate your pain? * 1. No pain. I can only feel pain if I look for it very carefully. 2. Slight, I can feel it when I look for it but not if I don't.3. Uncomfortable, but I can ignore it when I need to do important things. 4. Annoying, but I can do my daily chores without much difficulty.5. Distressing, I can perform only gross motor activities well.6. Hampering, I can't write or do stuff that requires paying attention. 7. Disabling, I can't do anything, and even have trouble talking.8. Agonizing; it hurts so much I can't walk. 9. Excruciating; I will do anything to end the pain right now! 10. Unbearable; I am hallucinating and lapsing out of consciousness. Chose which best describes your pain from the drop down menu How do you feel mentally? * Very SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedN/A How do you feel emotionally? * Very SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedN/A How is your sleep? * Very SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedN/A How is your digestion? * Very SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedN/A How is your exercise? * Very SatisfiedSatisfiedNeutralUnsatisfiedVery UnsatisfiedN/A Primary Pain * How long have you had the condition What's your BIGGEST dream for 2015? I am not seeking medical advice * Agreed, check the box
