Pain Questionnaire

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Call 270-298-7411

Chronic Pain Screening Questionnaire

Think you may need help managing your pain?
Please complete the following questionnaire to find out.

1. Are you experiencing pain that has lasted for 12 weeks or longer?:

2. Does pain prevent you from completing day-to-day activities?:

3. Does pain interfere with your sleep?:

4. Does pain affect your mood?:

5. Does pain contribute to your stress?:

6. Does pain limit your ability to sit, stand, or lift things?:

7. Does pain reduce your ability to engage socially?:

Based on your answers, you may be a good candidate for treatment at Ohio County Pain Care. For more information or to request a new patient appointment, please complete the contact form below. Or you can also reach out to us directly by phone at 270-298-5445.
Name:

Phone :

Email:

Ohio County Healthcare

Ohio County Healthcare is a non-profit Joint Commission accredited health system which provides a wide range of hospital, primary care and specialty physician services.

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What type of care do you seek?

Ohio County Healthcare offers a broad range of healthcare across a diverse landscape.

Ohio County Healthcare | 1211 Old Main Street, Hartford, KY 42347

Chronic Pain Screening Questionnaire

Think you may need help managing your pain? Please complete the following questionnaire to find out.

Based on your answers, you may be a good candidate for treatment at Ohio County Pain Care. For more information or to request a new patient appointment, please complete the contact form below. Or you can also reach out to us directly by phone at 270-298-5445.

Quick Links

What type of care do you seek?

Think you may need help managing your pain?
Please complete the following questionnaire to find out.