The Corpfit approach

We help guide you through what can be a challenging time.

We will communicate with your insurer, health professionals and other providers, keeping everyone up to date with treatment progress.

Our whole approach is centered on your needs; what is going to be the most appropriate and reasonable treatment and services to provide you with the best outcome for your specific situation.

Step 1 of 9

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Name(Required)

First Last

Phone(Required)

Email(Required)

Date

DD slash MM slash YYYY

Pain Screening Questionnaire.

Please provide a brief overview of your condition and any limitations you have as a result of this.(Required)

Please provide details regarding any social interests or hobbies which have been impacted as a result of your condition

Please provide any other information you feel may assist us in supporting you

How long have you had your current pain problem?(Required)

0-1 Weeks

1-2 Weeks

3-4 Weeks

4-5 Weeks

6-8 Weeks

9-11 Weeks

3-6 Months

6-9 Months

9-12 Months

Over 1 Year

How would you rate the pain that you have had during the past week?(Required)

Please select the one number which best describes your current ability to participate in each of these activities. 0 being no pain, 10 being as bad as it could be.

I can sleep at night.(Required)

0 = Can't do it because of the Pain 10 = Can do it without pain being a problem

I can do light work for an hour.(Required)

0 = Can't do it because of the Pain 10 = Can do it without pain being a problem

How much have you been bothered by feeling depressed in the past week?(Required)

0 = Not at all 10 = Extremely

In your view, how large is the risk that your current pain may become persistent?(Required)

0 = No risk 10 = Very large risk

In your estimation, what are the chances you will be working your normal duties in 3 months(Required)

0 = No chance 10 = Very large chance

How tense or anxious have you felt in the past week?(Required)

0 = Absolutely calm and relaxed 10 = As tense and anxious as I’ve ever felt

Here are some of the things which other people have told us about their pain. For each statement please select one number from 0-10 to say how much physical activities, such as bending, lifting, walking, or driving affect your pain.

An increase in pain is an indication that I should stop what I’m doing until the pain decreases.(Required)

0 = Completely disagree 10 = Completely agree

I should not do my normal work with my present pain.(Required)

0 = Completely disagree 10 = Completely agree

Please answer the questions below.

Please read each statement and select a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week.

There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

0 Did not apply to me at all

1 Applied to me to some degree, or some of the time

2 Applied to me to a considerable degree, or a good part of time

3 Applied to me very much, or most of the time

I found it hard to wind down(Required)

I was aware of dryness of my mouth(Required)

I couldn't seem to experience any positive feeling at all(Required)

I experienced breathing difficulty (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion)(Required)

I found it difficult to work up the initiative to do things(Required)

I tended to over-react to situations(Required)

I experienced trembling (e.g. in the hands)(Required)

I felt that I was using a lot of nervous energy(Required)

I was worried about situations in which I might panic and make a fool of myself(Required)

I felt that I had nothing to look forward to(Required)

I found myself getting agitated(Required)

I found it difficult to relax(Required)

I felt down-hearted and blue(Required)

I was intolerant of anything that kept me from getting on with what I was doing(Required)

I felt I was close to panic(Required)

I was unable to become enthusiastic about anything(Required)

I felt I wasn't worth much as a person(Required)

I felt that I was rather touchy(Required)

I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat)(Required)

I felt scared without any good reason(Required)

I felt that life was meaningless(Required)

The Corpfit approach

Pain Screening Questionnaire.

Please answer the questions below.

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