Have you tried several physical treatments and they have not reduced your symptoms?

Yes

No

Have doctors had difficulties finding a cause or full explanation for your symptoms?

Yes

No

Did your pain or symptoms emerge during, or after, a stressful time, life transition, or traumatic event?

Yes

No

Are your symptoms inconsistent?

Examples: o They are not always present. o Some days your symptoms are more intense, without a clear physical reason o The intensity level of symptoms changes over time, even while performing the same activities.

Yes

No

Do you have multiple pains or symptoms in several different areas of your body?

Yes

No

Do your pain or symptoms spread or move around to different body parts?

Yes

No

Do difficult emotions trigger your symptoms?

Yes

No

When you are relaxed or at ease, does your pain or symptoms reduce?

Yes

No

Do your pain or symptoms occur following an activity?

o Symptoms increase later in the day o Symptoms become worse in the following days

Yes

No

Are you prone to perfectionism, anxiety, high-control practices, or people-pleasing?

Yes

No

Does it feel like your nervous system is often in a reactive or stressed state of fight, flight, freeze, or shutdown?

Yes

No

Have you faced trauma or childhood adversity in your life?

*Note: This list only covers some examples of traumatic events. Examples: o Abuse in childhood or adulthood (physical, emotional, sexual) o Parental divorce o Being afraid of a family member o High conflict in the family o Bullying o Having a caregiver in childhood who had a mental health or addiction concern o Scary medical procedures, treatments, or care o High dysregulation (fight, flight, freeze, or shutdown) with the onset or progression of chronic pain or symptoms o Injuries or accidents o Life-threatening event

Yes

No