Chronic Pain Assessment Form

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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 *

First Name *

Last Name *

Gender *

Female

Male

Age *

18-25

26-34

35-45

45+

What describes your current body? *

I’m skinny fat. I have very little muscle definition and feel soft even though I’m not overweight.

I have long-held fat around my belly and I’ve love to get rid of that.

I’m not happy with the way I look. I see a lot of problem areas I’d like to change.

Option 4

What have you tried in the past to reduce your pain? *

Nothing. I mainly just live with it.

“Miracle” supplements to reduce pain and inflammation.

Mostly painkiller medication

Physical therapy

All the above

What sort of results have you achieved in the past? *

I have never been able to decrease my pain no matter what I try

I have had some improvement, here and there but it mostly comes back

Any time I get feeling better, I end up hurting myself even more down the road.

How many alcoholic drinks do you drink per week? *

I don’t drink

1-3

4-6

More than 7

How much stress do you experience during a typical day? *

I don’t feel much stress at all during the day.

I have some stress but it’s manageable

I have a lot of stress and I worry about it’s impact on my health

How many hours do you sleep a night? *

Less than 5

6-7

8-9

More than 9

How many times per week do you exercise? *

1-2

3-4

When you exercise, how hard do you push yourself? *

I don’t push at all. I take it easy and don’t break a sweat.

I raise my heart rate a bit and break a light sweat

I go pretty hard, I can’t have a full conversation without catching my breath

I go balls to the walls almost every time. Nothing left in the tank at the end.

How often do you think about your weight and how it affects your health? *

I rarely think about my weight and my health

I occasionally find myself conscious about my weight and health consequences

Most days I worry about my weight and health

My weight is a constant source of stress and anxiety

What would your ideal goal be for next month? *

I’d like to get rid of some excess fat around my gut and tone up so I can feel stronger

I’d like reduce my pain to regain the ability to play sports again.

I'd like to feel like I did when I first joined the military

All of the above

How much would your life change if you didn't have chronic pain? *

My life wouldn’t change that much

I think I'd be a bit happier and more content in life

I know my life would be easier and I would be much happier

My life would completely change if I could reach my goal weight.

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