Post-Evaluation

Name

First NameLast Name

Date of Birth

Areas of Pain

Any Changes in Pain Medication (Name, Amount, Frequency)

Sleep

How many times do you wake up at night due to pain?

How many hours of continual sleep?

Pain

Average Pain Level During Day with 0 "no pain", 10 "excruciating pain"

Highest Pain Level since starting class with 0 "no pain", 10 "excruciating pain"

Lowest Pain Level since starting class with 0 "no pain", 10 "excruciating pain"

Quality of Life

Please write a few sentences detailing your experience in class, and any changes you have noticed in your daily life.

Do you practice at home?

If yes, how often per week. [This does not include classes.]

If yes, for how many minutes per day. [This does not include classes.]