The document lists 21 potential activities and treatments for decreasing pain and asks the recipient to rate their willingness to try each option on a scale of 0 to 10. The options range from exercise, water aerobics, and stretching to weight loss, quitting smoking, physical therapy, and various relaxation or mindfulness techniques.

1. To decrease your pain how much would you be willing to: (circle your effort)
1
Exercise
0 1 2 3 4 5 6 7 8 9 10
2 Water Aerobics/Pool Therapy 0 1 2 3 4 5 6 7 8 9 10
3 Stretching 0 1 2 3 4 5 6 7 8 9 10
4 Attend Pain Education Groups 0 1 2 3 4 5 6 7 8 9 10
5 Use a TENS Unit 0 1 2 3 4 5 6 7 8 9 10
6 Lose Weight (If Applicable) 0 1 2 3 4 5 6 7 8 9 10
7 Stop Smoking (If Applicable) 0 1 2 3 4 5 6 7 8 9 10
8 Do Physical Therapy 0 1 2 3 4 5 6 7 8 9 10
9 Learn New Leisure Interests 0 1 2 3 4 5 6 7 8 9 10
10 Increase Activity Level 0 1 2 3 4 5 6 7 8 9 10
11 Screening or Treatment for Addiction (If
Applicable)
0 1 2 3 4 5 6 7 8 9 10
12 Decrease Pain Medication (If Applicable) 0 1 2 3 4 5 6 7 8 9 10
13 Stop Using Alcohol or Drugs (If Applicable) 0 1 2 3 4 5 6 7 8 9 10
14 Use Relaxation Therapy 0 1 2 3 4 5 6 7 8 9 10
15 Get Treatment for Anger, Depression, Anxiety 0 1 2 3 4 5 6 7 8 9 10
16 Learn Communication Skills 0 1 2 3 4 5 6 7 8 9 10
17 Do Yoga, Tai Chi, or other Meditative Techniques 0 1 2 3 4 5 6 7 8 9 10
18 Join an Activity Group 0 1 2 3 4 5 6 7 8 9 10
19 Try Acupuncture 0 1 2 3 4 5 6 7 8 9 10
20 Try Medical Marijuana 0 1 2 3 4 5 6 7 8 9 10
21 Try Chiropractic 0 1 2 3 4 5 6 7 8 9 10