Managing Chronic Pain without Medications: Before and 1 week after Scar Release Treatment
1.
Which community is closest to you ?
(Required.)
Prince George
Penticton
Comox / Courtney
2.
Which healthcare provider treated your chronic pain ?
(Required.)
Physician (Family Doctor)
Physician (Specialist)
Nurse Practitioner
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
(Required.)
0
1
2
3
4
5
6
7
8
9
10
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
(Required.)
0
1
2
3
4
5
6
7
8
9
10
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
(Required.)
0
1
2
3
4
5
6
7
8
9
10
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
(Required.)
0
1
2
3
4
5
6
7
8
9
10
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
(Required.)
0
1
2
3
4
5
6
7
8
9
10
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
(Required.)
0
1
2
3
4
5
6
7
8
9
10
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 ?
(Required.)
No change
5-25% less OTC pain medication
30-50% less OTC pain medication
55-75% less OTC pain medication
80-100% less OTC pain medication (non-prescription)
10.
PRESCRIPTION (Rx) pain medications: After your scar release treatment, are you now able to manage chronic pain with fewer prescription (Rx) pain medications ?
(Required.)
No change - still using same Rx pain meds
5-25% decrease in Rx pain med use
30-50% decrease in Rx pain med use
55-75% decrease in Rx pain med use
80-100 % decrease in Rx pain meds
11.
Optional: Please describe any quality of life changes you have experienced since scar release treatment.
(Required.)