Form
Name
First Name
Last Name
Email
example@example.com
Did your symptoms begin without a preceding injury?
Yes
No
If your symptoms started with an injury, has pain persisted after the injury's normal course of healing?
Yes
No
N/A
Did your symptoms begin during a stressful time?
Yes
No
Are your symptoms inconsistent (present some days but not others, move around the body, vary in intensity, etc.)?
Yes
No
Do you spend a lot of time worrying about your symptoms or checking in on your body?
Yes
No
Have you been told by doctors they cannot find anything wrong?
Yes
No
Do you have pain in multiple different parts of your body now, or have you in the past?
Yes
No
Do you have symptoms that mirror each other on left and right side of the body (i.e. pain in both knees)?
Yes
No
Does your pain worsen when you are feeling stressed?
Yes
No
Do your symptoms tend to lessen in intensity when you are engaged in something enjoyable?
Yes
No
Do you have pain after, rather than during activity?
Yes
No
Would you describe yourself as anxious, high achieving, self-critical, a perfectionist, or a people pleaser?
Yes
No
Did you experience significant stress as a child?
Yes
No
Do you have a family history of chronic pain or symptoms?
Yes
No
Submit
Should be Empty: