Pain Assessment And Treatment Equity Survey Form
Please complete this survey to help us understand your experiences with pain assessment and treatment equity. Your responses are anonymous and will be used to improve care quality and fairness.
What is your current level of pain?
*
1
2
3
4
5
6
7
8
9
10
Where are you experiencing pain? (Select all that apply)
*
Head
Neck/Shoulder
Back
Arms/Hands
Legs/Feet
Other
How long have you been experiencing this pain?
*
Please Select
Less than 1 week
1-4 weeks
1-6 months
More than 6 months
How would you rate the fairness of your pain assessment and treatment?
*
Very unfair
1
2
3
4
Very fair
5
1 is Very unfair, 5 is Very fair
Please indicate your agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I felt listened to during my assessment.
1
2
3
4
5
My pain was taken seriously.
6
7
8
9
10
I received clear explanations about my treatment.
11
12
13
14
15
I felt my background or identity did not affect my care.
16
17
18
19
20
How satisfied are you with the pain treatment you received?
*
Very satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Very dissatisfied
Did you experience any barriers to receiving pain assessment or treatment?
*
Yes
No
If yes, please briefly describe any barriers you faced.
What is your age group?
*
Please Select
Under 18
18-34
35-49
50-64
65 or older
Prefer not to say
Please share any additional comments or suggestions about your pain assessment and treatment experience.
Submit Survey
Should be Empty: