Psychological Support in Chronic Pain

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Full Name *

Age *

Location(s) of your pain

How long has it been present?

Diagnosis/diagnoses related to your pain

Treatments you are currently receiving

Department / physician following you for pain

What do you think about the cause of your pain and why it persists?

What worries you most about your pain?

Are there activities you used to do that you have reduced or stopped because of pain?

Yes

If yes, which ones?

What is the main reason you reduced or stopped these activities?

Have you previously received psychological/psychiatric support related to your pain or for another reason?

Yes

If yes, please briefly describe

In which area would you most like psychosocial support to help you?

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