Your relationship with pain

PAUSE with Bridget

This is your first step to reflecting on your relationship with pain. These questions simply give Bridget an accurate picture of you and your chronic pain condition.

Question Title

* Hi there! For the purpose of getting to know more about you and contacting you following this survey please list the following:

Name:

Phone number:

E-mail:

Age:

Employment status:

Occupation, if applicable:

Question Title

* In detail, please describe your chronic pain condition.

Question Title

* During this time, what treatments have you received? What's helped and what hasn't helped you?

Question Title

* Does your chronic pain interfere with your sleep? Please let us know how many hours sleep you’re getting, if it’s disrupted, if it’s difficult for you to get to sleep and any other details surrounding sleep.

Question Title

* Please describe your lifestyle. Include details regarding your diet, exercise, alcohol use, drug use, smoking consumption and hobbies/passions.

Question Title

* Do you take any medication? If so, please list type, amount and how long you have been taking them for.

Question Title

* What have been your main frustrations during your chronic pain experience?

Question Title

* Please list any limitations that you think you might have. Or are there any obstacles in your life that are contributing to your chronic pain?

Question Title

* At this point in time, do you have the ability and desire to explore your chronic pain condition? Are you committed to being fully engaged in bringing meditation techniques into your daily life? Please list any doubts that you might have.