Submit Your Story with Full Permission

Welcome to the Your Voice Matters story submission form. We look forward to reading your story!

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First Name

Last Name

Email Address

A photo helps bring your story to life. This photo will be shared with your story if you choose to upload one.

If you have a letter that's written, we invite you to upload it here.

Current Diagnosis (Primary & Secondary)

Are you unable to work productively or to the level you'd like? If so, how?

Are you having a hard time getting through your day because pain stops you? If so, how?

Are you avoiding medical appointments due to expense? If so, why?

Can you get appropriate medications or treatments for pain relief? Has that access changed over time? If so, how?

What obstacles prevent you from finding appropriate access to pain care, if any?

Have you disclosed your full diagnosis or experience with your chronic pain illness with those around you? If so, who? (Ex. Friends, family, co-workers, boss, etc.) If not, why?

Has your chronic pain illness affected your ability to work or your productivity? If so, how?

Has your chronic pain illness affected your education or career goals? If so, how?

Does chronic pain limit the activities you love most? If so, how?

Are you unable to participate in family or social activities? If so, how?

Are you hiding anxiety or feeling depressed about what the future holds with a chronic pain condition? If so, how?

Are you experiencing suicidal thoughts from fear or exhaustion in dealing with constant pain? If so, why?

Are you feeling that you have to defend your actions in seeking pain relief? If so, how?

What led you to seek a diagnosis, and what led a clinician to diagnose you? Were there any hurdles in achieving a diagnosis? If so, what?

Feel free to share anything else about your experiences with a chronic pain illness.

Birthdate (DD.MM.YEAR)

Address

City

State

Zip Code

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Submit Your Story with Full Permission

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