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INvisible Project: Health care disparities

U.S. Pain Foundation is looking for patients to feature in its upcoming INvisible Project magazine focused on health care disparities. Please fill out this form if you are interested in being featured. If you are selected, someone from U.S. Pain will contact you in 2-3 weeks.

1. Please provide your contact information. *This question is required.

First Name

Last Name

Street Address

City

State

Zip

Country

Email Address

Phone Number

2. Do you live with chronic pain? *This question is required.

3. Do you live with any of these specific conditions? Please check all that apply. *This question is required.

I don't have any of these conditions.
I have a condition not listed here. Please list: Please enter an 'other' value for this selection.
Neurological
Complex Regional Pain Syndrome or Reflex Sympathetic Dystrophy
Headache, Migraine, or Cluster Disease
Multiple Sclerosis
Nerve Pain or Neuropathy
Phantom Limb Pain
Trigeminal Neuralgia
Endocrinological
Diabetic-related Nerve Pain
Thyroid Disease
Musculoskeletal
Back Pain
Ehlers-Danlos Syndrome
Failed Back Surgery Syndrome

Fibromyalgia
Foot pain
Hand/wrist/elbow pain
Hip pain
Knee pain
Neck Pain
Osteoarthritis
Sciatica
TMJ
Gastrointestinal
Crohn’s Disease
Inflammatory Bowel Disease
Irritable Bowel Syndrome
Gynecological
Endometriosis

Interstitial Cystitis
Vulvodynia
Autoimmune/Rheumatological
Lupus
Psoriasis
Rheumatoid Arthritis/Disease
Hematological
Porphyria
Sickle Cell Disease
Oncological
Cancer Pain
Infectious Disease
Hepatitis
HIV/AIDs
Lyme Disease

4. What is your race/ethnicity?

5. Are you Hispanic or Latino(a)? *This question is required.

6. Are you LGBTQ+? *This question is required.

7. Why would you like to participate in the INvisible Project health care disparities edition? (300 word limit.) *This question is required.

8. Please list any organizations or resources that you have found helpful on the topic of disparities.