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START-1 TRIAL
After survey completion, please give to Dr. or Office Staff for submission.
Thank you.
TO PHYSICIAN OR OFFICE STAFF---
Upon Completion, please Fax or Upload completed survey to:
Clarity Research
To Submit Via Fax:
1-888-389-9193
To Submit Via Website Portal:
www.crcsciences.com
Clarity Research and Consulting
STUDY ID: START-1
PRACTICE Code: ____
Patient ID: ______________
MALE or FEMALE
1. PRIMARY COMPLAINT/DIAGNOSIS (Circle all that apply)
 Arthritis
Feet Hips Knees Neck Shoulders Back Other  Neuropathy or Radiculopathy (Radiating Pain)
 Myofascial/ Musculoskeletal Pain or Spasm
 Tendinitis
o Other __________________________
STUDY ID: START-1 Trial
Brief Pain Inventory (Short Form)
Pt ID: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches). Have you had pain other than these every- On the diagram, shade in the areas where you feel pain. Put an X on the area that Please rate your pain by circling the one number that best describes your pain at its Please rate your pain by circling the one number that best describes your pain at its Please rate your pain by circling the one number that best describes your pain on Please rate your pain by circling the one number that tel s how much pain you have STUDY ID START-1 Trial
PT. ID: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ What treatments or medications are you receiving for your pain? NO ANSWER NEEDED HERE- PLEASE SKIP
In the last 24 hours, how much relief have pain treatments or medications provided? Please circle the one percentage that most shows how much relief you have received.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Circle the one number that describes how, during the past 24 hours, pain has Normal Work (includes both work outside the home and housework) CURRENT MEDICATION USAGE (CHECK ALL THAT APPLY)
Over-the-Counter (OTC) Pain Medication
o Advil®, Motrin® (ibuprofen)
o ALEVE® (naproxen
o Aspirin (acetylsalicylic acid)
o Tylenol® (acetaminophen)
o Other
If you have indicated any medications taken above—What is Dose and How often per day?
Anti-Inflammatory (Prescription)
o Anaprox (naproxen sodium) o Dolobid (diflunisal)
o Naprosyn (naproxen)
o Celebrex (celecoxib)
o Feldene (piroxicam)
o Relafen (nabumetone)
o Clinoril (sulindac)
o Indocin
o Toradol (ketorolac tromethamine)
(indomethacin)
o Daypro (oxaprozin)
o Lodine (etodolac)
o Vimovo (naproxen/esomeprazole)
o Disalcid (salsalate)
o Mobic (meloxicam)
o Voltaren (diclofenac)
If you have indicated any medications taken above—What is Dose and How often per day?
Narcotic
o Avinza®, Kadian® (morphine)
o Lorcet®, Lortab®, Norco®, Vicodin® (hydrocodone)
o Demerol meperidine
o Opana® (oxymorphone)
o Dilaudid®, Exalgo® (hydromorphone) o Oxycontin®, Oxyfast®, Percocet®,
Roxicodone® (oxycodone and acetaminophen)
o Duragesic®, Fentora®, Actiq®
(fentanyl)
Neurontin® (gabapentin)
Lyrica®
(pregabalin)
Ultram®
(tramadol)
If you have indicated any medications taken above—What is Dose and How often per day?

Source: http://shcacs.files.wordpress.com/2013/10/start-1-survey-1-final9.pdf