The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

Mind Body Chronic Pain Interested Participant Survey

Thank you for your interest in the Mind Body Intervention for the Treatment of Chronic Pain.

This survey takes less than 2 minutes to complete and will provide more information about the study.

If you have any questions please reach out to us at 617-754-2882 or mindbodystudy@bidmc.harvard.edu.

We will be in touch shortly after the survey is completed.

Thank you!

Thank you for your interest in our study. We are looking for individuals who have chronic pain.

Full Name

* must provide value

Phone Number

* must provide value

What is your age?

* must provide value

Are you located in the United States?

* must provide value

Yes

reset

Which state do you live in?

How did you hear about this study?

* must provide value

Where did you see the flyer/poster/business cards?

Who referred you to the study?

From which social media site did you hear about this study?

When your back hurts, you may find it difficulty to do some of the things you normally do.

This list contains sentences that people have used to describe themselves when they have back pain. When you read them, you may find that some stand out because they describe you over the past week.

As you read the list, think of yourself over the past week. When you read a sentence that describes you in the last week, put a tick against it. If the sentence does not describe you, then leave the space blank and go on to the next one.

Remember, only choose the sentence if you are sure it describes you in the past week.

* must provide value

I stay at home most of the time because of my back.
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I change position frequently to try and get my back comfortable.
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I walk more slowly than usual because of my back.
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Because of my back, I am not doing any of the jobs that I usually do around the house.
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Because of my back, I use a handrail to get upstairs.
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Because of my back, I lie down to rest more often.
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Because of my back, I have to hold on to something to get out of an easy chair.
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Because of my back, I try to get other people to do things for me.
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I get dressed more slowly then usual because of my back.
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I only stand for short periods of time because of my back.
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Because of my back, I try not to bend or kneel down.
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I find it difficult to get out of a chair because of my back.
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My back is painful almost all the time.
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I find it difficult to turn over in bed because of my back.
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My appetite is not very good because of my back pain.
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I have trouble putting on my socks (or stockings) because of the pain in my back.
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I only walk short distances because of my back.
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I sleep less well because of my back.
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Because of my back pain, I get dressed with help from someone else.
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I sit down for most of the day because of my back.
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I avoid heavy jobs around the house because of my back.
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Because of my back pain, I am more irritable and bad tempered with people than usual.
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Because of my back, I go upstairs more slowly than usual.
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I stay in bed most of the time because of my back.
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None of the above apply to me

Thank you for completing the survey.
We will be in touch shortly with more information.
If you have any questions please call 617-754-2882 or email mindbodstudy@bidmc.harvard.edu.

Feel free to visit our website for more information at www.mindbodystudy.net.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.