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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.)

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If you are a combat veteran, in which conflicts did you serve? (please check all that apply)


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How intense is your pain on a daily basis? (0=no pain, 10=worst pain imaginable)












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Please select all the options that you are currently using for pain care:


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Where do you receive your pain care? Please select all that apply.


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Where are you getting emotional support now? Please select all that apply.


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Are you (please select all that apply):


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What is your race/ethnicity? (please select all that apply)


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

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City/State/ZIP:

 

    

 

 

 


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Highlights

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