Pain Survey - SurveyMonkey
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1. Untitled Page
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1
. On what date did you complete this questionnaire? NOTE: For all questions, click with the mouse in the field and type in your answer. When you are finished, click the "Done" button at the foot of this screen to send us the answers. If you want to exit the survey without sending us the answers, click "Exit this survey" at the top of this screen.
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Date
On what date did you complete this questionnaire? NOTE: For all questions, click with the mouse in the field and type in your answer. When you are finished, click the "Done" button at the foot of this screen to send us the answers. If you want to exit the survey without sending us the answers, click "Exit this survey" at the top of this screen. Date Month
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Day
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Year
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. Do you meet all of the following four conditions? 1) You are at least 18 years of age (and of legal age of consent in the state you live in). 2) Your pain has not resulted in a workman’s compensation case and has also not resulted in a lawsuit. 3) You are not institutionalized (e.g., a nursing home resident). 4) You are not currently participating in another clinical study. (You may take part in this study only if you meet all four conditions. If you do not meet all four conditions, you may not take part in the study and you should not complete the questionnaire).
Do you meet all of the following four conditions? 1) You are at least 18 years of age (and of legal age of consent in the state you live in). 2) Your pain has not resulted in a workman’s compensation case and has also not resulted in a lawsuit. 3) You are not institutionalized (e.g., a nursing home resident). 4) You are not currently participating in another clinical study. (You may take part in this study only if you meet all four conditions. If you do not meet all four conditions, you may not take part in the study and you should not complete the questionnaire).
Click button for Yes, leave blank for No
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. Have you read and understood the Informed Consent Form on the "Informed Consent Form" page at masterdocs.com and, having reviewed it, do you agree to take part in this study? (Only a Yes answer allows you to take part in the study. If you do not meet this condition, you may not take part in the study and you should not complete the questionnaire).
Have you read and understood the Informed Consent Form on the "Informed Consent Form" page at masterdocs.com and, having reviewed it, do you agree to take part in this study? (Only a Yes answer allows you to take part in the study. If you do not meet this condition, you may not take part in the study and you should not complete the questionnaire).
Click button for Yes, leave blank for No
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. Do you have CHRONIC PAIN (constant or recurring pain lasting more than 30 days and causing significant discomfort or limitation of activity)? Only a Yes answer allows you to take part in the study. If you do not meet this condition, you may not take part in the study and you should not complete the questionnaire.
Do you have CHRONIC PAIN (constant or recurring pain lasting more than 30 days and causing significant discomfort or limitation of activity)? Only a Yes answer allows you to take part in the study. If you do not meet this condition, you may not take part in the study and you should not complete the questionnaire.
Click button for Yes, leave blank for No
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. Do you have CHRONIC pain in the following parts of the body? (Check the box for each that applies, leaving the others blank)
Do you have CHRONIC pain in the following parts of the body? (Check the box for each that applies, leaving the others blank)
Head
Lower Back
Knee
Shoulder
Hip
Buttocks, or the back/outside of Thigh
Sole or Heel of Foot
Generalized Pain in both Feet
Other Pain in Leg or Foot
Other Part(s) of the Body
All Over the Body
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. If you checked the "Other Part(s) of the Body" box in the previous question, specify the other places you have chronic pain using the following code: a=neck, b=front of chest, c=upper back, d=upper abdomen, e=lower abdomen, f=elbow, g=wrist, h=elsewhere in arm, i=ankle, j=elsewhere - write in location
If you checked the "Other Part(s) of the Body" box in the previous question, specify the other places you have chronic pain using the following code: a=neck, b=front of chest, c=upper back, d=upper abdomen, e=lower abdomen, f=elbow, g=wrist, h=elsewhere in arm, i=ankle, j=elsewhere - write in location
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. Which is YOUR MOST TROUBLESOME pain (the one that bothers you most)? Check ONLY ONE box.
Which is YOUR MOST TROUBLESOME pain (the one that bothers you most)? Check ONLY ONE box.
Head
Lower Back
Knee
Shoulder
Hip
Buttocks, or the back/outside of Thigh
Sole or Heel of Foot
Generalized Pain in both Feet
Other Pain in Leg or Foot
Other Part(s) of the Body
All Over the Body
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. Which symptoms are associated with YOUR MOST TROUBLESOME PAIN? (Check the box for each symptom that applies, leaving the others blank)
Which symptoms are associated with YOUR MOST TROUBLESOME PAIN? (Check the box for each symptom that applies, leaving the others blank)
Change in amount of sweating
Change in appearance of painful area
Pain is aching
Pain is constant
Pain is cutting or knife-like
Pain is deep
Pain is horrendous
Pain is like an electric shock
Pain is pricking
Pain is throbbing
Pain is worse in evening
Pain is worse in morning
Pain is worse when upset or stressed
Pain limits or prevents standing up
Pain limits or prevents walking one city block (about 50 yards)
Pain is made better by movement
Pain is made worse with touch of clothing/bed sheets
Pain makes personal hygiene/grooming difficult
Painful area feels hot/burning
Painful area feels itchy
Painful area feels like pins and needles
Painful area feels numb
Painful area feels tight or stretched
Painful area feels tingling
Painful area is overly sensitive to cold
Painful area is overly sensitive to normal touch
Painful area is puffy or swollen
Painful area is stiff in morning
Painful area is weak
You stumble or fall in the dark more than before you started having this pain.
Other symptoms, problems with movement or limitations of function
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. If you checked the box for "Other symptoms, problems with movement or limitations of function", give details.
If you checked the box for "Other symptoms, problems with movement or limitations of function", give details.
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. How many months is it since you first started experiencing YOUR MOST TROUBLESOME PAIN?
How many months is it since you first started experiencing YOUR MOST TROUBLESOME PAIN?
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. Please look at the leg diagram below. Check the box for any colored area (green, red, blue) where you have pain -- all that apply. If you do not have pain in any colored area, leave all boxes blank.
Please look at the leg diagram below. Check the box for any colored area (green, red, blue) where you have pain -- all that apply. If you do not have pain in any colored area, leave all boxes blank.
Green
Red
Blue
Leg Diagram
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. Your Name
Your Name
First Name
Last Name
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. Your Address (NOTE: either a mailing or email address is REQUIRED -- provide both if you can. Please specify the State you live in, even if you do not provide your full mailing address.)
Your Address (NOTE: either a mailing or email address is REQUIRED -- provide both if you can. Please specify the State you live in, even if you do not provide your full mailing address.)
Address 1
Address 2
City
State
Zip Code
Email Address
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. Age (NOTE: We would really like your age in years, but you can keep it vague if you prefer, e.g., "over 18". However, please don't give an inaccurate answer, as this affects the integrity of our data.)
Age (NOTE: We would really like your age in years, but you can keep it vague if you prefer, e.g., "over 18". However, please don't give an inaccurate answer, as this affects the integrity of our data.)
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. Gender (Click Male or Female)
Gender (Click Male or Female)
Male
Female
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. Will you draw your pain areas and email the pain drawing to us? NOTE: This is a VERY IMPORTANT part of this survey as it will determine how detailed our response to you can be. We also believe it will help in the diagnosis of the causes of chronic pain in people like you. (After you complete the questionnaire and click the "Exit this survey" or "Done" buttons, this window on your screen will be replaced with a window containing pain drawing instructions.)
Will you draw your pain areas and email the pain drawing to us? NOTE: This is a VERY IMPORTANT part of this survey as it will determine how detailed our response to you can be. We also believe it will help in the diagnosis of the causes of chronic pain in people like you. (After you complete the questionnaire and click the "Exit this survey" or "Done" buttons, this window on your screen will be replaced with a window containing pain drawing instructions.)
Click button for Yes, leave blank for No
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. May we contact you with additional questions? (NOTE: You would only be contacted with questions about this study or future clinical studies we may do -- and only by the study staff.)
May we contact you with additional questions? (NOTE: You would only be contacted with questions about this study or future clinical studies we may do -- and only by the study staff.)
Click button for Yes, leave blank for No
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. Are you willing to help us by contacting others to let them know about this study? NOTE: It would be very helpful if you could send information about this clinical study to other people who may have chronic pain (e.g., people on your email contacts list). If you feel your relatives or friends might like to take part in the study, just suggest they go to the masterdocs.com site on the Internet. Chronic pain is very common -- depending on how we define it, it affects about 1/4 to 1/2 of the population. If you are willing to let others know about this study, we might be able to complete the study earlier, and therefore release the results earlier. In addition, as soon as we have enrolled enough subjects in the study, we will make the full diagnostic information at masterdocs.com available to anyone on the Internet, not just to those who have returned our questionnaire. We would appreciate your help in spreading the word about this study. Thank you.
Are you willing to help us by contacting others to let them know about this study? NOTE: It would be very helpful if you could send information about this clinical study to other people who may have chronic pain (e.g., people on your email contacts list). If you feel your relatives or friends might like to take part in the study, just suggest they go to the masterdocs.com site on the Internet. Chronic pain is very common -- depending on how we define it, it affects about 1/4 to 1/2 of the population. If you are willing to let others know about this study, we might be able to complete the study earlier, and therefore release the results earlier. In addition, as soon as we have enrolled enough subjects in the study, we will make the full diagnostic information at masterdocs.com available to anyone on the Internet, not just to those who have returned our questionnaire. We would appreciate your help in spreading the word about this study. Thank you.
Click button for Yes, leave blank for No
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. Additional Information you would like to provide to us (e.g., more about your pain symptoms, questionnaire questions that are unclear, how long it took you to complete the questionnaire, which instructions did not work on your particular computer, how you heard about this study, whether you found the Web site slow, if you had problems with email, or suggestions as to how we could provide better questions or more useful information. You can enter up to 5000 characters.).
Additional Information you would like to provide to us (e.g., more about your pain symptoms, questionnaire questions that are unclear, how long it took you to complete the questionnaire, which instructions did not work on your particular computer, how you heard about this study, whether you found the Web site slow, if you had problems with email, or suggestions as to how we could provide better questions or more useful information. You can enter up to 5000 characters.).
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