Striving to Thriving


Your Toolbox

NOTE: These appendices will be live once the manuscript/book is published.

This is the toolbox for both patient and provider(s). Since many of the tools, templates, assessments, logs, etc. are repeatedly copied they are available here instead of forcing the user/reader of the book to continually copy pages from the book. Like any other toolbox, not everyone needs all the tools all the time, just as no one single patient needs all the assessments, templates, logs, etc. All the appendices are available in one file HERE. Using this file requires the user to know how to find, select and print specific pages as needed, otherwise, each “tool” is individually provided below.

Appendix 1 – Current Medications List

Appendix 2 – Healthcare Provider Contact Information

Appendix 3 – Systems Review is a listing of common physical/biological health conditions.

Appendix 4 – Pain Medications – Just as it implies, this is a list of the most common medications used in pain management.

Appendix 5 – Pain Descriptors and Assessment – This provides the physician/therapist with specific information regarding your pain, such as location, quality, intensity, cause and location(s). etc.

Appendix 6 – Potential Pain Triggers -Many things can affect your pain. These can include stress, sleep, money worries, and even the weather. Pain can adversely affect one’s entire biopsychosocial being. When you and your doctor understand what makes your pain worse, you can begin to work together on ways to reduce or deal with your pain “triggers.”

Appendix 7 – Office Visit Prep Questions – These are recommended questions the patient should ask their pain management providers. This shows the provider(s) that the patient is prepared for the office visit before the provider enters the room.

Appendix 8 – Questions to Ask Your Doctor on the Day of Your First Appointment – These questions help both the patient and provider to make the most of the first office visit and gets the patient mentally engaged and thinking before that first appointment. This has to potential to show the provider that the patient is serious about engagement level.

Appendix 9 – Office Visit, Goals, Questions and Concerns – This is a snapshot of one’s activities, goals ADLs (activities of daily living) and QOLs (quality of life). This is completed by the patient and given  to the provider. This worksheet serves multiple purposes, but mainly providing data for assessing measurable outcomes, treatment plan efficacy and patient progress. The patient should complete and give this to their provider(s) for EACH office visit. The data should be entered into the EMR system.

Appendix 10 – Patient Health Questionnaire (PHQ-9) – The PHQ-9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression: The PHQ-9 incorporates DSM-IV depression diagnostic criteria with other leading major depressive symptoms into a brief self-report tool.

Appendix 11 – Monthly Pain Log – This log provides the prescriber valuable information regarding medication efficacy. The prescribing physician can use this to evaluate if dosing changes are needed. The instructions for use printed at the top are, “For each day of the month, in the table below, indicate the time your pain started, where the pain is and the activities that may have started or worsened your pain and any medication you took for relief of pain. Write the corresponding numbers in the cells under each day. Using an “X” indicate AM or PM and the level of relief you obtained and how long after taking the medication you felt relief.”

Appendix 12 – Stretching Log Sheet – This is a checklist for the patient to use to ensure they perform any stretching the providers assign.

Appendix 13 – Walking Log – This log captures steps taken, distance traveled, time goals and ideas captured on the walks. This is another data capture tool for both providers and patients.

Appendix 14 – Sleep Log – This 14 day sleep log captures 8 sleep metrics both patient and provider can use to quantify sleep hygiene and quality.

Appendix 15 – Weekly Migraine Log – This log helps gather data related to assessing migraine triggers.

Appendix 16 – Stress Indicators Questionnaire – This assessment examines physical, sleep, behavioral, emotional and personal habit indicators related to stress inducing risks.

Appendix 17 – General Stress Self-assessment – This self-assessment provides only an indication to patient and providers to determine if interventions may be required. Some of the questions asked, such whether or not you want to fly in a commercial aircraft, may simply reflect preference vs. anxiety. The assessment considers panic attacks, general anxiety, PTSD, OCD, social phobias and fear of flying.

Appendix 18 – Anger Assessment – The is a self-assessment that examines thoughts, processing, events, behaviors, attitudes, etc. related to anger behavior or patterns.

Appendix 19 – Generalized Anxiety Disorder 7-item (GAD-7) Scale – The GAD-7 is a quick and simple assessment of anxiety in only seven questions. When used as a screening tool, further evaluation is recommended when the score is 10 or greater. Using the threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82% for GAD. It is moderately good at screening three other common anxiety disorders – panic disorder (sensitivity 74% , specificity 81% ), social anxiety disorder (sensitivity 72% , specificity 80% ) and post-traumatic stress disorder (sensitivity 66% , specificity 81% ).

Appendix 20 – Depression Risk Factors -This assessment is to determine the level of potential risks depression may play in your life. Take notice that of the 10 risks below, the six highlighted below are common to those struggling with chronic pain. The purpose of this assessment is to provide you a quantifiable level of risk you have to depression and to graphically show the likelihood of specific risks of depression common to those with chronic pain. A higher score DOES NOT indicate you ARE depressed. It simply means risk factors exist of which you should be aware.

Appendix 21 – Feelings of Shame Scale – Sometimes those with chronic pain experience shame for both internal and external reasons. This assessment helps measure the influence shame might play in how one processes life and their pain experience.

Appendix 22 – Guilt and Shame Experience Scale (GSES) – This is a quick assessment for the guilt and shame experiences. Guilt is concerned with the negative evaluation of a specific behavior in a particular situation, resulting in a desire to confess, apologize, and repair. In contrast, shame involves the negative evaluation of the self and elicits a desire to vanish or escape. In other words, guilt is a negative feeling much more related to the specific event, rather than to the self. In contrast, shame involves a global negative feeling about the self in response to some misdeed or failure that is often triggered by a social event in which a drop of personal status or feelings of rejection are perceived.

Appendix 23 – Migraine Questionnaire – This questionnaire asks the per with migraine about the nature, frequency, intensity, location, etc. of the migraine attacks as well as potential triggers for migraines.

Appendix 24 – OIC (Opioid Induced Constipation) Assessment – The assessment helps both patient and provider better understand what side-effects (and life-style causes) must be addressed in order to reduce OIC.

Appendix 25 – Negative Emotions and Feelings That Can Arise from Your Pain Experience – This is a list of feelings and emotions commonly associated with the pain experience. Its purpose is for use in expressive writing exercises to help patients describe their experience.

Appendix 26 – Feelings, Attitudes and Behavior Descriptors – This is a more extensive list than that in Appendix 25 as it includes feelings, emotions, attitudes and behaviors.

Appendix 27 – Anti-inflammatory Food Pyramid – This is a graphic showing the types of food considered anti-inflammatory and their proportions.

Appendix 28 – Weekly Success Plan – This template is for both patient and providers to use. It provides a weekly snapshot or review of those things that might (or should) be included in SMART Goals or overall treatment plan. This is a valuable tool for helping one stay motivated to work “the plan.”

Appendix 29 – SMART Goals Worksheet  –  This template is used to develop or define goals that are Specific, Measurable, Attainable, Relevant and Time-bound.

Appendix 30 – Expressive Writing Prompts by Chapter – Writing prompts are provided at the end of each chapter in the book. For convenience they are provided here.

Appendix 31 – Ten High-impact Chronic Pain Conditions – This was initially part of the text in the book but was removed and placed here because this information is general and not serve or support specific needs, but still provides insight and information on multiple pain conditions.

Appendix 32 – Parts of the Brain – This material is more detailed and is available for those who want more information on the various parts of the brain and what they do.

Appendix 33 – The Body’s Nervous Systems – This material is more detailed and is available for those who want more information on the various parts of the nervous systems and what they do.




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