CENTRAL SENSITIZATION INVENTORY: PART A
Please circle the best response for each statement
I feel tired and unrefreshed when I wake from sleeping.
*
Never
Rarely,
Sometimes,
Often
Always
My muscles feel stiff and achy.
*
Never
Rarely,
Sometimes,
Often
Always
I have anxiety attacks..
*
Never
Rarely,
Sometimes,
Often
Always
I grind or clench my teeth.
*
Never
Rarely,
Sometimes,
Often
Always
I have problems with diarrhea and/or constipation.
*
Never
Rarely,
Sometimes,
Often
Always
I need help in performing my daily activities.
*
Never
Rarely,
Sometimes,
Often
Always
I am sensitive to bright lights.
*
Never
Rarely,
Sometimes,
Often
Always
I get tired very easily when I am physically active.
*
Never
Rarely,
Sometimes,
Often
Always
I feel pain all over my body.
*
Never
Rarely,
Sometimes,
Often
Always
I have headaches.
*
Never
Rarely,
Sometimes,
Often
Always
I feel discomfort in my bladder and/or burning when I urinate.
*
Never
Rarely,
Sometimes,
Often
Always
I do not sleep well.
*
Never
Rarely,
Sometimes,
Often
Always
I have skin problems such as dryness, itchiness, or rashes.
*
Never
Rarely,
Sometimes,
Often
Always
I have difficulty concentrating.
*
Never
Rarely,
Sometimes,
Often
Always
Stress makes my physical symptoms get worse.
*
Never
Rarely,
Sometimes,
Often
Always
I feel sad or depressed.
*
Never
Rarely,
Sometimes,
Often
Always
I have low energy.
*
Never
Rarely,
Sometimes,
Often
Always
I have muscle tension in my neck and shoulders.
*
Never
Rarely,
Sometimes,
Often
Always
I have pain in my jaw.
*
Never
Rarely,
Sometimes,
Often
Always
Certain smells, such as perfumes, make me feel dizzy and nauseated..
*
Never
Rarely,
Sometimes,
Often
Always
I have to urinate frequently.
*
Never
Rarely,
Sometimes,
Often
Always
My legs feel uncomfortable and restless when I am trying to go to sleep at night.
*
Never
Rarely,
Sometimes,
Often
Always
I have difficulty remembering things.
*
Never
Rarely,
Sometimes,
Often
Always
I suffered trauma as a child.
*
Never
Rarely,
Sometimes,
Often
Always
I have pain in my pelvic area.
*
Never
Rarely,
Sometimes,
Often
Always
CENTRAL SENSITIZATION INVENTORY: PART B
Have you been diagnosed by a doctor with any of the following disorders?Please check the box to the right for each diagnosis.
*
Yes
No
Restless Leg Syndrome
Chronic Fatigue Syndrome
Fibromyalgia
Temporomandibular Joint Disorder (TMJ)
Migraine or Tension Headaches
Irritable Bowel Syndrome
Multiple Chemical Sensitivities
Neck Injury (including whiplash)
Anxiety or Panic Attacks
Depression
Name
*
First Name
Last Name
Total Score
Submit
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