1) Do you find that your pain level is related to the amount of tension/stress you are experiencing or to how you are coping with your feelings?
Definitely___
Yes, have noticed this, at times___
Not really__

Would you describe yourself as in general, "very hard on yourself", "highly responsible for others", or "very thorough, orderly, or perfectionistic"?
Definitely____
Yes, I've noticed I have some of these characteristics__
Not really____

3)Have you suffered from other tension-related illnesses such as:
--hives, eczema, rashes brought on by tension
--spastic colon, irritable bowel, gastritis, reflux/heartburn
--tension or migraine headaches
--unexplained prostate trouble or pelvic pain
Definitely, two or more categories______
Yes, at least one______
No_________

4) Have you been told regarding the cause of your pain that "there's nothing that can be done surgically", "there's nothing wrong", "it's a soft tissue problem", or "the cause is degenerative changes"?
Yes_____
No_____

5) Do you spend a great deal of time during the day thinking and worrying about your pain, looking for an answer, obsessing about its cause?
Yes____
No_____

6) Have you tried several different treatments or approaches for your pain and received only temporary relief from each or no relief from any of them?
Yes____
No_____

7) Do you find that massage helps your pain significantly OR that you are quite sensitive to massage in several parts of our back or neck?
Yes____
No_____