Thank you for taking the time to participate in this survey

Many readers comment on the financial toll chronic pain brings to individuals and families. National Pain Report is conducting this survey to gain a better understanding of the extent that pain impacts personal finances.

* 1. Name & Email Address

* 2. Do you suffer from chronic pain?

* 3. How do the effects of chronic pain (lost work, healthcare costs, disability, etc.) influence your economic situation?

* 4. Are you employed?

* 5. Overall, how would you rate your economic situation?

* 6. How would you describe your current credit rating?

* 7. Rank each of the following in terms of its most negative impact on your finances.

  No negative impact Some negative impact Large negative impact
Direct medical costs
Debt related to pain / healthcare
Cost of being unemployed (on disability)
Cost of being underemployed (pain keeps you from promotions)

* 8. If scholarship money were available to you, would you accept it in order to advance your education and improve your earning ability?

* 9. Should National Pain Report create a scholarship fund for people in pain (adults and children) to advance their education and help combat the financial ramifications of pain?

* 10. If National Pain Report created a scholarship fund for people in pain, would you consider donating to the scholarship?

* 11. If you answered "Yes" to Question 10, how much would you consider donating?

* 12. Are you unable to secure credit (like a new credit card) due to your financial circumstances?

* 13. Have you ever filed for bankruptcy?

* 14. How familiar are you with pre-paid debit cards as an alternative to costly checking accounts, or as a means to manage budgets and shop online?

* 15. I estimate pain has cost me in lost productivity, healthcare costs, lost job opportunity:  (select one)

* 16. Many people carry debit or credit cards that carry a message or represent an organization, for example American Cancer Society’s Relay for Life Visa.  Would you carry a card that expresses something related to pain?