Required fields are marked with an asterisk *.

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Sleep Patterns

Do you have difficulty getting to sleep? *
Why do you wake up? (Mark all that apply)
Do you rest during the day? *
Please rate your quality of sleep on the following scale. *
Do you ever feel rested when you wake up? *
What helps you sleep better? (Mark all that apply)
Do you use medications to sleep? *
Have you ever tried medications that have not worked? *

Nutritional Habits and Fitness Limitations

If less than three, why?
Do you snack? *
Do you eat fast food? *
Do you drink caffeinated beverages? *
Are you familiar with different food groups? *
Overall, do you think you are a healthy eater? *
Do you take vitamins or other supplements routinely? *
Is your schedule flexible?
Have you had an ergonomic evaluation (correct sitting/standing guidelines *
Are you on disability? *
Do you participate in any scheduled exercise (work out/aerobics)? *
Are you able to do household chores? *
If yes, what chores can you complete? (mark all that apply)

Social

Do you drink alcohol? *
Do you use medical marijuana? *
Do you use recreational drugs to treat your pain? *
Do you use tobacco products? *
Have you been prescribed pain medication? *
Do you live alone? *
Do you have family who understands your condition? *

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things.
Feeling down, depressed, or hopeless. *
Trouble falling or staying asleep, or sleeping too much. *
Feeling tired or having little energy. *
Poor appetite or overeating. *
Feeling bad about yourself — or that you are a failure or have let yourself or your family down. *
Trouble concentrating on things, such as reading the newspaper or watching television. *
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual. *
Thoughts that you would be better off dead or of hurting yourself in some way. *
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *

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