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* 1. Do you have a chronic or recurring condition that requires medication or treatment for pain?

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* 2. If so, what is your diagnosis? (Mark all that apply.)

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* 3. Do you currently take opioids (narcotics) for your pain?

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* 4. If so, how often do you take opioids?

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* 5. Have you tried other therapies or medications to relieve your pain?

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* 6. If so, how do those compare to opioids?

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* 7. Do you think restrictions on the use of long-term opioids for chronic conditions harms chronically ill patients?

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