Development privacy notice: this review form is in development and is not currently a HIPAA-compliant production intake. It is used to generate and email a printable PDF for review. After confirmed submission, the form website does not intentionally retain your answers. The emailed PDF is retained in the sender's Gmail Sent Mail and 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. Submissions are sent to Lofland and blind copied to Developer.

Lofland review delivery

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. You can use left and right arrows to select an answer, then Tab to move to the next question.

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. Use up and down arrows to select an answer, then Tab to move to the next question.

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.

Lofland review delivery

Submission Preview

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Submissions are sent to Lofland and blind copied to Developer. Use PDF Preview before sending when reviewing answers. 

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Development privacy notice: this review form is in development and is not currently a HIPAA-compliant production intake. It is used to generate and email a printable PDF for review. After confirmed submission, the form website does not intentionally retain your answers. The emailed PDF is retained in the sender's Gmail Sent Mail and recipient mailbox according to their email retention settings.