The American Pain Foundation: Military Veterans Survey

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Military/Veterans Survey

Pain is a growing concern among the military, veterans, their loved ones and caregivers. In order to better understand and serve you, we ask that you complete the following survey. This survey is geared toward military and veteran personnel who suffer chronic pain either from battlefield injuries, injuries sustained while on active duty or from other sources of chronic pain. Caretakers of these individuals are also encouraged to take this survey. If you do not fit into these categories, but know someone who does, please ask them to complete this survey which can be found on our Military/Veteran in Pain page.

(We take your privacy seriously and know it is important to honor. We will not sell or rent this information to others. We will share this information only with your permission. For more information about our privacy policies, click here.)

Question - Not Required - Are you currently serving (Active Duty or National Guard/Reserves)?

Question - Not Required - Are you a veteran?

Question - Not Required - Are you a combat veteran?

Question - Not Required - If you are a combat veteran, in which conflicts did you serve? (please check all that apply)

	WWII
	Korea
	Vietnam
	First Gulf War
	OIF
	OEF
	Other

Question - Not Required - If other, please let us know which conflict/s:

Question - Not Required - What is the primary diagnosis or cause of the pain that you or your family member/friend have?

Question - Not Required - What is the secondary diagnosis or cause of pain that you or your family member/friend have?

Question - Not Required - How long have you had pain?

Question - Not Required - How intense is your pain on a daily basis? (0=no pain, 10=worst pain imaginable) 0
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5
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10

10.

Question - Not Required - Is your pain directly related to your military service?

11.

Question - Not Required - Are you an amputee?

12.

Question - Not Required - Do you have Post Traumatic Stress Disorder (PTSD)?

13.

Question - Not Required - Do you have depression?

14.

Question - Not Required - How much has pain interfered with your quality of life? (On a scale of 1=Not at all to 5=Very Much)

15.

Question - Not Required - How much has pain interfered with your ability to work? (On a scale of 1=Not at all to 5=Very Much)

16.

Question - Not Required - How much has pain interfered with your relationships? (On a scale of 1=Not at all to 5=Very Much)

17.

Question - Not Required - Do you feel that seeking pain treatment compromises your status as a member of the military or your career in the military?

18.

Question - Not Required - Do you feel that your training to be stoic is a barrier to seeking pain care?

19.

Question - Not Required - Have you experienced difficulties obtaining prescription medications for pain?

20.

Question - Not Required - Have you ever felt that you were being treated as "drug seeking" or a "drug addict" when obtaining prescription medications for pain?

21.

Question - Not Required - Have you been referred to or received care from a pain specialist?

22.

Question - Not Required - Do you have access to multiple options for pain care and treatment?

23.

Question - Not Required - Please select all the options that you are currently using for pain care:

	Medication
	Physical Therapy
	Exercise/Stretching Program
	Chiropractor
	Acupuncture
	Occupational Therapy
	Nutritional Support/Counseling
	Injection Therapies/Infusion Therapy
	Implanted Spinal Cord Stimulator
	Implanted Drug Delivery System
	Behavioral Therapy
	Relaxation Techniques
	Biofeedback
	Meditation
	Stress Management
	Other

24.

Question - Not Required - Where do you receive your pain care? Please select all that apply.

	Civilian Medical Practice
	Veterans Administration
	Other

25.

Question - Not Required - If other, please specify:

26.

Question - Not Required - What is the average wait time to schedule an appointment with your current provider?

27.

Question - Not Required - How effective has your pain care been? (On a scale of 1 = Very Ineffective to 5 = Very Effective)

28.

Question - Not Required - How important is it to you to have emotional support as part of your pain management? (On a scale of 1 = Not Important at All to 5 = Very Important)

29.

Question - Not Required - Where are you getting emotional support now? Please select all that apply.

	Family
	Friends
	Group Counseling
	Individual Counseling
	Faith Community
	Online Support
	None
	Other

30.

Question - Not Required - If other, please specify:

31.

Question - Not Required - Would you be willing to help us advocate for state and national legislative efforts to improve pain care policy?

32.

Question - Not Required - Are you (please select all that apply):

	A person with pain
	A family member or friend of someone with pain
	A healthcare provider

33.

Question - Not Required - Please select your age range:

34.

Question - Not Required - What is your gender?

35.

Question - Not Required - What is your race/ethnicity? (please select all that apply)

	Asian/Asian American/Pacific Islander
	Black/African American
	Latino/Hispanic
	Native American
	White
	Other
	Decline to Answer

36.

Question - Not Required - If other, please specify.

37.

To receive more information from the American Pain Foundation, including a free packet of educational materials, please complete the following:

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