Edgewood Pain Management Screening 1. Are you experiencing pain that has lasted for 12 weeks or longer? Yes No 2. Does pain prevent you from completing day-to-day activities? Yes Sometimes No 3. Does pain interfere with your sleep? Yes Sometimes No 4. Does pain affect your mood? Yes Sometimes No 5. Does pain contribute to your stress? Yes Sometimes No 6. Does pain limit your ability to sit, stand, or lift things? Yes Sometimes No 7. Does pain reduce your ability to engage socially? Yes Sometimes No Name(Required) First Last Email(Required) PhoneAdditional Information
