Clinical Trial Regular Survey

The information you provide on this form is critical in assessing the effectiveness or otherwise of SDR Therapy for chronic pain.

You can be completely confident in the confidentiality of this information, and in fact of any information you share with us before, during or after the trial. The site is protected by both an SSL certificate and by comprehensive security software. As we collate this information from trial participants we “anonymise” it, which means that it isn’t possible to identify any person from the raw data which is shared. This is how we share data and findings without risking breaching your privacy.

We’ll ask you to complete this same survey prior to beginning the trial, at approximately 1 month into the trial, at 6 months, 12 months, and finally at 2 years. The reason we repeat the process is not just to look at the difference that SDR Therapy can make for most people, but whether the benefits last long term. By being this thorough, we can be confident that we’re putting SDR Therapy to the most rigorous testing possible.

Thank you again for being part of this trial.



    The next question refers to medication which you may be taking for the pain you have that is the subject of the trial. It is not about medication you may take from time to time for unrelated issues. For example you may take medication for back pain, but currently you have a toothache and are taking additional medication for that. The toothache medication should not be taken into account for this survey.

    Since I have enrolled in this clinical trial:

    I have not taken pain medication.I have increased pain medication.I have decreased pain medication.I have not changed my pain medication.

    Click only 1 button from the list below in order to indicate the severity of your pain:

    Pain level 0 - No painPain level 1 - Unpleasant sensation - an occasional uncomfortable feeling. Almost no limit to function. (Example: mild skin irritation)Pain level 2 - Minimal - pain frequently brought to one's attention but acceptable. Able to engage in pleasures of life with some interference. Causes to avoid rigorous activities. (Example: small bruise)Pain level 3 - Mild - tolerable, but upsetting and on one's mind. Interferes with pleasure of life. Stops some productive activities.Pain level 4 - Mild to moderate. only short intervals of comfortable function; sometimes interrupts activities of daily living, such as bathing and clothing and regularly prevents involvement in many tasks outside of the home. Decrease in job performance. (Examples: major bruise or ankle sprain)Pain level 5 - Moderate - pain constantly on one's mind; decrease in concentration, job performance and noticeably decreased enjoyment of life. Frequent missed work/time off. Cannot perform normal tasks without an increase in pain. (Examples: moderate toothache, headache for days)Pain level 6 - Moderate to severe - significant limitations of activities of daily living; productive activity/work is nearly impossible. Hard to do anything, but think of pain and emergency room visit. (Example: day after major surgery pain)Pain level 7 - Severe - difficulty doing more than basic chores; pain prevents productive activity. Frequent crying; pain is impossible to tolerate for long period of time without going to the emergency room. (Examples: stabbed with a knife, broken leg)Pain level 8 - Debilitating - Causes uncontrollable moaning and distress and completely impairs productive activity. Cannot be still, can't maintain a reasonable conversation. It is impossible to put on a good face. Emergency medical attention is required. (Examples: natural childbirth, small kidney stone)Pain level 9 - Agonising - individual cannot function; uncontrolled screaming and tearfulness. Emergency medical attention is required and hospitalisation is recommended. (Examples: arm burning in a fire, large kidney stone)Pain level 10 - Worst imaginable - paralyzing; person is in and out of consciousness and near death as a result of pain. Emergency medical attention AND hospitalisation are required. (Example: being torn apart while still alive)


    Function level 0 - No interference with activity (completely independent) - can complete daily activities; work/volunteer daily; active participant in family/social life; active on weekends, normal quality of life; complete household and yard work.Function level 1 - Slightly modified activity - can take part in family and social life; can work/volunteer 8 or more hours daily; some weekend activity, complete household and yard work with increased fatigue but independent.Function level 2 - Minimal limitations - can work/volunteer a few hours daily; active 5 or more hours each day; ca plan and keep 1 or more social events during evenings or on weekends; can complete household/yard chores with some strain; may need help with some activitiesFunction level 3 - Mild limitations - can work in or out of home for a few hours a week; active for 3-5 hours daily; can complete activities of daily living and household chores with help needed 15-25% of the time.Function level 4 - Mild to moderate limitation - can complete some more complex household tasks with help needed 30-45% of the time; occasional missed work/volunteer; limited social activities.Function level 5 - Moderate limitations - can leave the house only 1-2 times a week (unrelated to work or important appointments); can complete daily hygiene; can complete some daily household tasks with help needed 50% of the time.Function level 6 - Moderate to severe limitation - can complete only simple household tasks with help needed 60% of the time, unable to grocery shop; can talk to others on the phone; can only leave house for important appointments/emergencies.Function level 7 - Severe limitation - in bed half the day almost every day; can get dressed, shower, watch television, make phone calls and do minimal household tasks with help 70% of the time; leave home only for emergencies, usually with assistance.Function level 8 - Severe to maximal limitation - in bed more than half the day every day, some contact with others in the home; limited self care activity needing help 80% of the time; leave home only for emergencies and only with assistance.Function level 9 - Maximal limitation - in bed most of the day every day; limited contact with others; minimal to no self care activity and help needed 90% of the time; completely home bound.Function level 10 - Totally dependent - unable to get out of bed all day every day; no self care; no function possible without assistance.


    In this final section of the survey we're interested in finding out whether or not you're affected by depression or anxiety, how well you're sleeping, and how you feel about life in general.

    Each item below has a rating of zero for never, 1 for sometimes, 2 for usually, and 3 for always. This can't be exact for obvious reasons, so just pick the number which best represents your thoughts, and feel free to use the message box below to provide any more information you'd like to share.

    I feel happy most of the time. 0123

    I feel positive about the future. 0123

    I feel that I can succeed at getting what I want. 0123

    I feel pleasure in several aspects of my life. 0123

    I have mostly said goodbye to guilt. 0123

    I am a person of value and worth and I deserve good things in life the same as everyone else. 0123

    I like myself and I'm generally happy with myself. 0123

    I believe I'm a good person. 0123

    I have a lot to live for. 0123

    I can laugh and cry appropriately and that's fine. 0123

    I react fairly calmly when things don't go the way I wish. 0123

    I generally find people interesting. 0123

    I like making my own decisions about my life. 0123

    I am happy with my appearance. 0123

    I am happy with my level of productivity. 0123

    I sleep well and wake refreshed. 0123

    I have all the energy I want or need. 0123

    I enjoy good food. 0123

    I'm maintaining a healthy weight, or am moving toward a healthy weight at a rate I'm comfortable with. 0123

    My health is good for my age. 0123

    I enjoy my sexuality. 0123

    Thank you for completing this survey and helping to amass the information needed to assess whether or not SDR Therapy is able to help people who are experiencing chronic pain. Click the "Send" button below to send this confidential survey to us.