Central Sensitization Inventory: Part A
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please select the best response to the right of each statement.
*
Rows
Never
Rarely
Sometimes
Often
Always
1. I feel tired and unrefreshed when I wake from sleep.
2. My muscles feel stiff and achy.
3. I have anxiety attacks.
4. I grind or clench my teeth.
5. I have problems with diarrhea and/or constipation.
6. I need help in performing my daily activities.
7. I am sensitive to bright lights.
8. I get tired very easily when I am physically active.
9. I feel pain all over my body.
10. I have headaches.
11. I feel discomfort in my bladder and/or burning when I urinate.
12. I do not sleep well.
13. I have difficulty concentrating.
14. I have skin problems such as dryness, itchiness, or rashes.
15. Stress makes my physical symptoms get worse.
16. I feel sad or depressed.
17. I have low energy.
18. I have muscle tension in my neck and shoulders.
19. I have pain in my jaw.
20. Certain smells, such as perfumes, make me feel dizzy and nauseated.
21. I have to urinate frequently.
22. My legs feel uncomfortable and restless when I am trying to go to sleep at night.
23. I have difficulty remembering things.
24. I suffered trauma as a child.
25. I have pain in my pelvic area.
Total
Have you been diagnosed by a doctor with any of the following disorders?
*
Rows
No
Yes
If Yes, Year Diagnosed
1. Restless Leg Syndrome
2. Chronic Fatigue Syndrome
3. Fibromyalgia
4. Temporomandibular Joint Disorder (TMJ)
5. Migraine or tension headaches
6. Irritable Bowel Syndrome
7. Multiple Chemical Sensitivities
8. Neck Injury (including whiplash)
9. Anxiety or Panic Attacks
10. Depression
Submit
Should be Empty: