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Rate Your Pain

This self-assessment survey may be helpful in determining whether your pain is treatable with an Empi Select device. Pease remember that only your physician should help you determine whether you are a good candidate for this therapy.

Choose a number between 0 and 10 that BEST describes your average level of pain.

Worst Possible Pain No Pain

How long have you experienced pain?

Less than 3 months

3 months - 1 year

More than 1 year

Is your treatment regimen helping to relieve your pain?

Yes

Tell us about the treatments you have tried: (Check all that apply)

I have taken more than one kind of medication for my pain.

My pain medication does not relieve my pain.

Oral medications, injections, and/or physical therapy have not done enough to relieve my pain.

Surgery has failed to relieve my pain.

I have been examined by a medical professional and diagnosed with cancer, nerve damage, chronic infection, or other chronic condition.

I have visited a pain specialist in an effort to relieve my pain.

Do you experience breakthrough pain? (Times when your current treatment can't handle your pain)

Yes

Describe your quality of life: (Check all that apply)

Pain prevents me from participating in my usual daily activities.

I have experienced a recent increase or change in my pain.

Uncomfortable side effects from current treatments have made life less enjoyable for me and/or my family.

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