Date of Birth
Areas of Pain
Any Changes in Pain Medication (Name, Amount, Frequency)
Use Pain Medication
Do Not Use Pain Medication
How many times do you wake up at night due to pain?
How many hours of continual sleep?
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.]
less than 5 minutes
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