Introduction: This self-assessment tool is designed to help you evaluate your pain, management techniques, functional abilities, and other factors as you prepare for travel. Please answer each question as honestly and thoroughly as possible. Where instructed, select the indicated number of options. If none of the choices fully capture your experience, please choose “Other” and provide your response.
Note: This tool is for self-assessment only and is not a substitute for professional medical advice. Consult your healthcare provider for personalized recommendations.

EVALUATION OF PAIN

1. What is your primary pain condition? (Choose all that apply)

Fibromyalgia Trigeminal neuralgia Chronic pelvic pain Arthritis Neuropathy Migraine Other:

2. How would you describe your pain? (Select all descriptors that apply)

Sharp Burning Throbbing Dull Aching Stabbing Other:

3. How intense is your pain on a scale of 0-10 (consider your average pain level)? (Choose one)

0-2 (Mild) 3-4 (Moderate) 5-6 (Severe) 7-8 (Very Severe) 9-10 (Unbearable) Fluctuates unpredictably Other:

4. How would you describe the pattern of your pain? (Choose all that apply)

Constant Intermittent Unpredictable Worsens with movement Worsens with rest Cyclical Other:

5. What are your main pain triggers? (Select all that apply)

Weather changes Stress Physical exertion Travel-related factors Sleep disturbances Dietary choices Other:

6. Where do you experience the most pain? (Select all that apply)

Head Neck/Shoulders Back Joints Abdomen Legs/Feet Other:

EVALUATION OF EXISTING PAIN MANAGEMENT TECHNIQUES

1. What medications are you currently using for pain relief? (Choose one or more as applicable)

NSAIDs (e.g., ibuprofen) Opioids Antidepressants (e.g., duloxetine) Anticonvulsants (e.g., gabapentin) Muscle relaxants Topical treatments Other:

2. What procedures have you tried for pain relief? (Choose one or more as applicable)

Nerve blocks Epidural injection Surgery Neuromodulation Radiofrequency ablation Chemical neurolysis Implanted pumps Stem-cell therapy Platelet-rich plasma injection Other:

3. What non-medication approaches have you tried? (Select all that apply)

Physiotherapy Acupuncture Mindfulness/meditation Massage therapy Heat/cold therapy Breathing techniques Other:

4. What is your most effective method for immediate pain relief? (Choose one)

Medication Stretching Resting Applying heat/cold Distraction techniques Hydration/nutrition Other:

EVALUATION OF FUNCTIONING: PHYSICAL, PSYCHOLOGICAL, SOCIAL

Physical

1. How does pain affect your mobility? (Choose one)

No impact Slightly limits movement Requires frequent breaks Requires assistive devices Prevents certain movements Severely limits movement Other:

Psychological

1. How does pain impact your mood? (Choose one)

No impact Occasional frustration Frequent frustration Mild anxiety/depression Severe anxiety/depression Emotional exhaustion Other:

Social

1. How does pain affect your ability to engage in social activities? (Choose one)

No impact Slight discomfort Need frequent breaks Need to leave early Avoid social situations Completely isolates me Other:

EVALUATION OF OTHER FACTORS CONTRIBUTING TO THE PAIN EXPERIENCE

1. Do you experience sleep disturbances due to pain? (Choose one)

Never Rarely Sometimes Often Always Unsure Other:

2. How do dietary habits affect your pain levels? (Choose one)

No effect Some foods worsen pain Some foods relieve pain Pain is unpredictable I manage pain through diet I haven’t considered this Other:

MOTIVATIONS AND PREFERENCES

1. What is your primary motivation for traveling? (Choose one)

Adventure Relaxation Family/friends Work Medical reasons Spiritual retreat Other:

PUTTING IT ALL TOGETHER

1. What are your top three concerns about managing pain while traveling? (Select up to three)

Medication availability Mobility limitations Travel-related stress Lack of rest opportunities Unpredictable pain episodes Missing out on activities Other:

2. What three action steps can you take to prepare for pain management on your trip? (Select up to three)

Packing a pain-relief kit Scheduling rest periods Researching medical facilities Adjusting my itinerary Seeking pre-travel medical advice Practicing relaxation techniques Other:

Conclusion

By completing this self-consultation tool, you gain a clearer understanding of your pain patterns, management strategies, and overall travel readiness. This proactive planning can help you design a travel experience that better aligns with your health and personal goals. Remember, while this tool provides valuable insight, it does not replace professional medical guidance.

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