Veteran Registration

Please allow for enough time to complete the course in one session. You will have to start over if you exit without completing all activities to the finish page.

required *

Your provider's first name *

Your provider's last name *

VISN *

Facility *

How old are you? *

How many years have you had pain that interferes with your life? *

What is your gender? *

Male
Female

What is your marital status? *

Married
Single
Divorced
Widowed

What is your employment status? *

Working full-time or full-time student
Working part-time or part-time student
Retired
Unemployed
Disability pay is my major source of income

How satisfied are you with your medical care for pain? *

Very unsatisfied
Unsatisfied
Neutral
Satisfied
Very Satisfied

Have you been deployed to either Afghanistan or Iraq? *

Yes
No

Do you have a personal history of alcohol or other drug abuse? *

Yes
No

Are you currently being prescribed opioids/narcotics (oxycodone, methadone, vicodin, Percocet, etc.)? *

Yes
No

How do you rate your quality of life? *

0 Stay in bed all day. Feel hopeless and helpless about life.
1 Stay in bed at least half the day. Have no contact with outside world.
2 Get out of bed but don’t get dressed. Stay at home all day.
3 Get dressed in the morning. Minimal activities outside of home two days a week.
4 Do simple chores around the house. Minimal Activities outside of home two days a week.
5 Struggle but fulfill daily home responsibilities. No outside activity. Not able to work/volunteer.
6 Work/volunteer limited hours. Take part in limited social activities on weekends.
7 Work/volunteer for a few hours daily. Can be active at least five hours a day. Can make plans to do simple activities on weekends.
8 Work/volunteer for at least six hours daily. Have energy to make plans for one evening social activity during the week. Active on weekends.
9 Work/volunteer/be active eight hours daily. Take part in family life. Outside social activities limited.
10 Go to work/volunteer each day. Normal daily activities each day. Have a social life outside of work. Take an active part in family life.