*1. Have you had pain persisting past three months after normal tissue healing, trauma, surgery or unknown cause?

*2. Has your pain interfered with your productivity at work, resulted in absenteeism or loss of employment?

*3. Has your pain impacted your quality of life and reduced your functional capabilities?

*4. Do you have difficulty organizing your thoughts or with memory or learning?

*5. Have you developed depression and anxiety?

*6. Does your pain include a burning sensation?

*7. Do you have a painful cold or freezing sensation?

*8. Do you have tingling or feeling of pins and needles?

*9. Do you have numbness or a sensation like wearing an invisible glove or sock?

*10. Do you have itching?

*11. Do you experience normal sensations like touch as extremely painful?

*12. Do you have a loss of balance or coordination?

*13. Do you have sharp,shooting, or electric- like pain?

*14. Have you tried various types of therapy for pain or prescription drugs and still failed to get sustained relief?

*15. Do you have a medical condition resulting in episodic or constant pain?