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Contento Health : Your Pain in Personal

1Sleep, Energy and Concentration

How many hours do you sleep a night on average?*

0

1

2

3

4

5

6

7

8

9

10
Do you have enough energy?*

Too Little

Enough

Too Much
Do you have problems concentrating or focusing?*

Not Really

It's Sometimes a Problem

I Often have a Problem

2Health (including pain symptoms and overall health)

The PEG is a validated screen to measure the impact of pain. The PEG score is most useful in tracking changes over time. [PMID 19418100] The PEG score should decrease over time after therapy has begun.

The least amount of pain you can Imagine =0 and the most you can imagine =10.

What is your highest pain level over the past week?*

0

1

2

3

4

5

6

7

8

9

10
What number best describes how, during the past week, pain has interfered with your enjoyment of life?*

0

1

2

3

4

5

6

7

8

9

10
What number best describes how, during the past week, pain has interfered with your general activity?

0

1

2

3

4

5

6

7

8

9

10
Have you EVER been told by a doctor or other health professional that you had*

...Glaucoma

...Cancer or a malignancy of any kind *

...HIV or Hepatitis

...Crohn's disease or ulcerative colitis

...Multiple sclerosis

...Epilepsy or seizure disorder

...Some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia *

...Some other form of chronic pain disorder

...Diabetes *

...Chronic Obstructive Pulmonary Disease or COPD, emphysema or chronic bronchitis *

...Migraine Headaches

...Coronary heart disease *

...Hypertension, also called high blood pressure *

...Any type of depression *

...Any type of anxiety disorder *

...Post-traumatic stress disorder or PTSD

...Opioid use disorder

...Alcohol or other substance use disorder (other than opioid)

None

Other
Do you use cannabis to help with any of these conditions

...Glaucoma

...Cancer or a malignancy of any kind *

...HIV or Hepatitis

...Crohn's disease or ulcerative colitis

...Multiple sclerosis

...Epilepsy or seizure disorder

...Some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia *

...Some other form of chronic pain disorder

...Diabetes *

...Chronic Obstructive Pulmonary Disease or COPD, emphysema or chronic bronchitis *

...Migraine Headaches

...Coronary heart disease *

...Hypertension, also called high blood pressure *

...Any type of depression *

...Any type of anxiety disorder *

...Post-traumatic stress disorder or PTSD

...Opioid use disorder

Alcohol or other substance use disorder (other than opioid)

None

Other
Which health aspects of your conditions are most bothersome to you?*

Sleep

Appetite / Gastrointestinal

Pain

Energy

Addiction

None

Other

3Anxiety and Depression: Over the past two weeks, how often have you been bothered by the following symptoms?

The PHQ-4 an evidence based assessment for anxiety and depression. The PHQ score, like most other screening instruments, is most useful in tracking changes over time. The PHQ score should decrease over time as symptoms improve. PHQ-4 risk score is rated as normal (0-2), mild (3-5), moderate (6-8), and severe (9-12). Total score ?3 for first 2 questions suggests anxiety. Total score ?3 for last 2 questions suggests depression.

0 No or Low Risk

1 Low score

2 Moderate risk of condition

3 High risk of condition

Feeling nervous, anxious or on the edge?*

0

1

2

3
Not being able to stop or control worrying?*

0

1

2

3
Feeling down, depressed or hopeless?*

0

1

2

3
Little interest or pleasure in doing things?*

0

1

2

3

4Optional Information

Which of any of the following holistic alternatives do you use to help manage your health / pain?

Yoga

Meditation

Vegetarian / Other forms of healthy diet

Regular Exercise

Massage

Accupuncture
Methods - If you use cannabis, which ways do you prefer to consume?

Smoke flower

Vaporize flower

Inhale oil or other concentrate

Edibles

Topical

Other
How many times have you ever used cannabis?

Never

Less than a dozen

Under a hundred

More than a hundred
Acknowledging most marijuana labels do not highlight whether the strain is indica, hybrid or sativa which composition is your preference? Indica is more relaxing and Sativa more active.

Indica

Hybrid - Indica

Hybrid - Equally Balanced Indica and Sativa

Hybrid - Sativa

Sativa

All of the above
I prefer - CBD / THC / Mixed?

CBD Dominant

THC Dominant

Mixed to enhance clinical benefits

If you would like to save your results and be able to follow your progress over time we offer a subscription which would allow you to see.

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Disclaimer: If you would like to save your assessment then you need to login first and make sure your subscription has not expired. If you don't have an account then register and please subscribe so you can save your results and they will be charted when you take future assessments.

This form is to be used if you are 21 years old or greater. This form is not a diagnostic instrument and is only to be used within the context of you sharing your status with your care provider. The maker and provider of the Contento Assessment disclaims any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of any of this material.

Personal pain management and sleep review to share with your clinician. The following is provided as an organizational resource and not to be used as medical information. If you feel at risk of harm or hurting yourself please contact Lifeline at 1-800-273-8255 or proceed to the closest emergency room.

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