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1. Which community is closest to you ?

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2. Which healthcare provider treated your chronic pain ?

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3. What number best describes your pain on average in the week BEFORE your treatment ?
0 - No pain, 10 - Pain as bad as you can imagine

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4. What number best describes how, in week BEFORE your treatment, pain had interfered with your enjoyment of life?
0 - Did not interfere, 10 - Completely interfered

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5. What number best describes how, in the week BEFORE your treatment , pain had interfered with your general activity?
0 - Did not interfere, 10 - Completely interfered

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6. 1 WEEK AFTER TREATMENT: What number best describes your pain on average in the past week following your treatment?
0 - No pain, 10 - Pain as bad as you can imagine

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7. 1 WEEK AFTER TREATMENT: What number best describes how, during the past week AFTER treatment, pain has interfered with your enjoyment of life?
0 - Does not interfere, 10 - Completely interferes

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8. 1 WEEK AFTER TREATMENT: What number best describes how, during the past week after treatment, pain has interfered with your general activity?
0 - Does not interfere, 10 - Completely interferes

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9. OVER THE COUNTER (OTC) pain medications: After being treated with scar release therapy, are you now able to manage chronic pain with fewer over the counter (OTC) / non-prescription pain medications ?

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10. PRESCRIPTION (Rx) pain medications: After your scar release treatment,  are you now able to manage chronic pain with fewer prescription (Rx) pain medications ?

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11. Optional: Please describe any quality of life changes you have experienced since scar release treatment.

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