HIPAA / privacy process notice: this form is used only to generate and email a printable PDF. After confirmed submission, the form website does not retain your answers. The emailed PDF is retained only in the sender's Gmail Sent Mail and the recipient mailbox according to their email retention settings.

How to fill out this form

  1. Enter the participant name, then answer every question.
  2. Use Tab to move to the next question row. Use the left and right arrow keys to change the selected answer for the focused question.
  3. Use PDF Preview to review the one-page summary before sending. Test delivery remains Wayne-only.

Test delivery mode

Lofland status check-up

Fill the questionnaire, submit it, and keep this window open until confirmation appears.

Partispant

Current Level of Disability

Choose one score from 0, no disability, to 10, total disability.

Statements About the Past Two Weeks

Choose the one statement in each group that best describes the way you have been feeling during the past two weeks, including today.

Symptoms During the Past Week

Choose how much each symptom bothered you during the past week, including today.

Thoughts and Feelings When in Pain

Choose the degree to which you have each thought or feeling when experiencing pain.

Test delivery

Submission Preview

Nothing has been submitted yet.

Test mode sends only to Wayne's Gmail while production delivery remains disabled. Use PDF Preview before sending when reviewing answers. 

{}

HIPAA / privacy process notice: this form is used only to generate and email a printable PDF. After confirmed submission, the form website does not retain your answers. The emailed PDF is retained only in the sender's Gmail Sent Mail and the recipient mailbox according to their email retention settings.