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Beyond Pain App Report

The following report is based on answers I supplied while completing the “Beyond Pain App”. This report does not provide diagnoses nor treatment recommendations. The report provides information about my pain and is to help with the work we do together to address my pain and activity.

Name:
Date of this report:

ACTIVITY GOALS

Things I’d like to do if I can reduce my pain:

MY HEALTHCARE

The way I’m feeling about he pain care I’ve received:

Things that have been going well with my care:

Things that have not been going well with my care:

PAIN DESCRIPTION

I have experienced pain continuously or pain that has come and gone over the past:

Pain location:

Front
Back

Over the past 3 months, I have had pain on:

Over the past 3 months, pain has limited my life or work activities:

  • 0
    No Pain
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
    Pain as bad as you can imagine
How Pain is Impacting Me (PEGS)
  • Average Pain
  • 0
    No Interference
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
    Completely Interferess
  • Pain interfered with enjoyment of life
  • Pain interfered with general activity
  • Pain interfered with sleep

WORRIES AND CONCERNS

It’s not really safe for a person with a condition like mine to be physically active:

I feel that my pain is terrible and it’s never going to get any better:

I am not able to work due to pain or a pain condition:

  • Never
  • Some Days
  • Most Days
  • Every Day
Symptoms of Depression and Anxiety
  • Little interest of pleasure in doing things
  • Feeling down, depressed, or hopeless
  • Feeling nervous, anxious or on edge
  • Not being able to stop or control worrying

CURRENT TREATMENT AND MANAGEMENT

  Body Movement and Awareness Treatments  Core Pain Management Skills  Integrative Health Practices  Conventional Medical Treatments 
Using and helpful 
Used but not helpful
I’d like to learn more 
Not interested 
Did not view
  • Physical Therapy
  • Occupational Therapy
  • Regular physical activities
  • Yoga
  • Tai Chi
  • Other mind-body practices - Alexander Technique
  • Other mind-body practices - Feldenkrais
  • Ergonomics
  • Assistive devices
  • Understanding Pain
  • Relaxation Techniques
  • Pain Psychotherapies
  • General Psychotherapies
  • Acupuncture
  • Massage
  • Chiropractic care
  • Cannabinoids
  • Oral Medication - Acetaminophen
  • Non-steroidal Anti-inflammatory Drugs (NSAIDs)
  • Opioids
  • Antidepressants
  • Anticonvulsants
  • Topical Pain Medications
  • Diagnostic and Therapeutic Injections for Chronic Pain
  • Ice / Cryotherapy
  • Heat Therapy
  • Transcutaneous Electrical Nerves Stimulator (TENS)
  • Surgery for chronic pain
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