Chronic Pain Questionnaire

First Name

Last Name

Middle Initial

Address

City

State

Zip Code

Phone Number

Email

Date of Birth

Social Security Number

What increases your pain?

What decreases or relieves your pain?

Please list prescriptions and medications.

How does your chronic pain affect your life on a daily basis? ( Make sure to specifically talk about each topic listed with as much detail as possible) Physical Activity/ Employment, Marital, Family, Social

What is your height?

What is your current weight?

What did you weigh in Basic Training?

Please explain your education and work history.

Any legal or behavioral history?

Yes

No

If "Yes" please explain:

History of substance abuse?

Yes

No

If "Yes" please explain:

Previous treatment or diagnosis of a mental health condition?

Yes

No

If "Yes" please explain:

Is there a specific event or situation in service that you feel has affected your mood?

Yes

No

If "Yes" please explain:

Chronic Pain Checklist

Please check all that apply below:

Anxiety

Panic attacks that occur weekly or less often

Depressed mood

Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively

Difficulty adapting to stressful circumstances, including work or work like settings

Impaired abstract thinking

Suicidal ideation

Disturbance in motivation or mood

Chronic sleep impairment

Inability to establish and maintain effective relationships