Pain Check-In

Pain Check-In
This form is used as a quantitative evaluation of how your pain has been controlled since we last spoke. Please answer the following questions considering your experience over the last 4 weeks. For the purposes of these questions, please use the Pain Scale depicted & following considerations:

Pain Score of 0 = no pain at all
Pain Score of 4 = pain is becoming distracting
Pain Score of 8 = cannot do anything because of the pain
Pain Score of 10 = childbirth, kidney stones, worst pain imaginable
Email*
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Pain Scale
Most of us will experience aches & pains as time goes on, though severity can vary greatly. Where have you experienced your most significant pain?*
Rate Your Baseline/Usual Level of Pain*

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Worst Pain Experienced in the last 4 weeks*

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Current Level of Pain Right Now*

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In the last few days only, how often have you experienced your worst pain?*
# of visits to chiropractor in last 4 weeks*
# of visits to physical therapist in last 4 weeks*
# of visits to massage therapist in last 4 weeks*
# of visits to other therapists (e.g. CBT, DBT, EMDR, pain reprocessing, acupuncture, myofunctional & more!)*
Our bodies needs proper nutrition to both heal & strengthen. How closely does your diet match the recommended diet shown here?
Very well. I understand the connection between diet and inflammation and strive to follow a diet similar to the one shown here.I eat clean & avoid processed food, but my diet doesn't look like thisI do ok on some of these things but mostly follow a typical American diet.I haven't considered how diet connects to my pain, but will look for trends & connections.How can diet matter? I'm skeptical of this, but open to learning more.I don't want to talk about my diet.Other
How does pain affect what you connect to as your life's purpose?
Please input your answer here*
Stress leads to chronic inflammation, associated with every major age-related disease. Are you taking time to downshift each day to shed that stress?*

Yes, I get plenty of rest.Yes, I'm able to downshift under usual circumstances.No, but I'm going to re-structure my life to allow for it going forward.No because it seems impossible to do.Other
Are you a trauma survivor?*

YesNoI'm not sure
How often have you felt angry or enraged in the last 4 weeks?*
What is the baseline level of pain you are hoping to achieve through treatment? *

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How well do you think your pain is controlled overall?*
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Pain Check-In

Pain Scale

Our bodies needs proper nutrition to both heal & strengthen. How closely does your diet match the recommended diet shown here?