Stanford Division of Pain Medicine: Prescreening Survey

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Thank you for your interest in participating in our research study! The purpose of this study is to examine the effect of chronic pain and pain medication on brain function. For more information about the study, please visit this link. We are specifically looking for adults between the ages of 21 and 65 who experience chronic low back pain as their main source of pain and discomfort.

The following survey will allow us to determine whether you are eligible to participate. Please read the information sheet to understand the purpose of this survey, how we plan to use your information, and how you can contact us or reach an independent contact. You may also print the information sheet for your records.

Some important points before you begin:

Please complete this survey in one sitting. It should take approximately 15 minutes.
Please have your current and previous medication records handy.
It is extremely important for our research that you answer every question truthfully.
Please rest assured that your information will be held safely and securely and will not be shared with any third party.

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.