Pain and Discomfort Survey

This survey is part of a study conducted by Optimum Dental Posture, addressing the prevention and management of chronic pain in the dental profession. Thank you for your participation.

Privacy Statement

All details collected in this form are private and confidential. No personal details will be distributed to any party. Information provided in this survey will be used as anonymous data for research purposes only.

I have read and understood the Privacy Statement

For the results of this research and future Optimum Dental Posture Programs

Full Name

First NameLast Name

E-mail

Please tick appropriate box

If you are a specialist please indicate your field

How many years have you been practising?

1. Have you been experiencing pain, discomfort, tingling or numbness?

At Work

Outside of Work

2. Where have you been experiencing pain or discomfort? (Tick all relevant boxes)

3. Rate the intensity of the (worst) pain or discomfort (if you have more than one symptom)

During Work

	1	2	3	4	5	6	7	8	9	10

1 is None, 10 is High

Outside of Work

	1	2	3	4	5	6	7	8	9	10

1 is None, 10 is High

4. What is the impact of the pain or discomfort on your working life?

5. What is the impact of the pain or discomfort on your life outside work hours?

6. Have you sought any help for the pain or discomfort? (Tick all relevant boxes)

7. Has pain or disability forced you to take time off work?

8.How has your pain or disability changed over time?

9. What do you find most challenging about your work that might be causing or aggravating your symptoms? (Please tick all relevant boxes)

Other

Thank you for completing this survey.

Please provide email address if you are interested in this research and future Optimum Dental Posture Programs & Workshops