Thank you for joining the battle against chronic pain. Any data collected for research will be used anonymously. If you would like to share your pain experience with me and your results with the pain research community, copy and paste this information into the CONTACT form or email me – judydercksen@gmail.com. Please note I cannot answer emails but will try to blog information I feel will help our pain community.

DATA

Name and email optional

My pain at its max out of 10 is           At its least is                /10     on Average        /10

It has been present for at least 6 months, even if only sometimes  Yes or No

I have back pain      Yes or No

I have pain in multiple other sites  Yes or No

Gender:

Age:

My total score from the Self Report Form is /80

Thank you very much.

Judy   judydercksen@gmail.com

Please don’t use for spam or sending me ideas for the website or your products. Please respect the work pain warriors are doing to fight pain.