Name * First Name Last Name Email * Phone * Country (###) ### #### DOB * MM DD YYYY 1. During the past week, have you had any pain or would you have had pain if not for the treatment you are receiving? * yes no maybe 2. Is this pain present continuously (most of the day) on most days or would the pain persist if not for the treatment you are receiving? * yes no maybe . During the past week, on average, how would you rate your baseline pain on a scale of 0 to 10? 3 * Mild 0-3 Moderate 4-7 Severe 8-10 4. Assess the nature of your baseline pain. * Aching Agonizing Annoying Beating Burning Cold Cramping Crushing Cutting Dull Exhausting Flashing Freezing Hot Itchy Intense Nauseating Numb Pinching Pounding Pressure Pulsing Radiating Sharp Shooting Sore Spreading Stabbing Throbbing Tight Tingling Unbearable 5. Please describe what reduces your pain. * 6. Are you taking Opioids daily? Please explain. * 7. Do you have periods during the day when you have temporary episodes of uncontrolled pain (also known as breakthrough pain)? * 8. How long does it take from the time you first notice the pain until it is at its worst? * 8a. How long do the episodes last? How long does it usually take from the time you take medicine until the pain goes away? * 9. Do you know what causes these breakthrough pain episodes? * 9a. Are the episodes associated with certain activities (for example, gardening, walking)? yes no 9b. Does the onset occur with certain bodily functions(for example, coughing, sneezing)? yes no 9c. Does the onset usually occur right before a scheduled dose of your pain medication? yes no 10. Are these episodes of breakthrough pain the same type of pain as your usual pain? 11. Do the episodes of breakthrough pain affect your ability to handle daily responsibilities at home or work? * 12. To what extent does avoiding activities due to fear of an episode of breakthrough pain compromise your quality of life? * Strongly Disagree Disagree Neutral Agree Strongly Agree 13. Does anything help lessen the severity of these episodes of breakthrough pain? * 14. In the past 24 hours, how long has it taken for your breakthrough pain medication to begin to take effect? 15. In the past 24 hours, how satisfied or dissatisfied have you been with how fast your breakthrough pain medication began to reduce your breakthrough pain? * Strongly Disagree Disagree Neutral Agree Strongly Agree Next Steps: What are you looking to gain? * Info & Tips Treatment Recommendations See the Herbalist Start a Standard Wellness Plan Customize a Wellness Plan Alternative to Insurance We don't accept insurance but have options so that you could get the plan you need. FSA HSA Thank you! We understand your pain and want to help you get back to feeling good naturally.
