Chronic Pain Syndrome also known as Reflex Sympathetic Dystrophy (RSD) RSD Questionnaire

Chronic Pain Syndrome/Reflex Sympathetic Dystrophy (RSD) Questionnaire Where do you live? (City/province or state) _____________________________ My age is ____________ years and ________ months. Or birth date____________________ Where is the injury? (example left elbow _________________________________________ My injury occurred on (date) _____________________________________________ pain began how long after injury?( days/weeks/months)___________________________ First diagnosis of illness/disease________________________________ If this was not an injury but related to an existing disease or a reoccurrence of a disease, please state the disease or disorders you have ______________________________ Have you been diagnosed with RSD by a doctor? _______________ or an alternative name used for RSD ___________________________________________________ If you have not been diagnosed but strongly believe you have all the symptoms of this disorder, what is your doctor currently calling your condition?____________________ Why do you believe it is CRPS/RSD and your doctor does not? Explain____________________________________________________________________ How long did it take to be diagnosed with RSD following the onset of pain/injury?_________ yrs _________ months. How did your pain begin-please underline or circle one of the following: Unknown _____________ At home______________ Car accident_______________ Work related injury________________ Describe the ‘initial’ symptoms you experienced?_______________________________________________________________ Who first diagnosed you with this disorder? Example- medical doctor, PT, pain specialist, rheumologist ___________________________________________ what name did the doctor use for this condition? (Example-RSD, CRPS, Causalgia, Hand/shoulder syndrome or any other names) ____________________________________ Aside from pain and the symptoms in your limb, do you suffer any other symptoms or syndromes since the pain began? Describe_________________________________________________________ Are you CRPS Type 1 (RSD) or Type II (RSD with proven nerve injury)_________________________ Has your doctor or specialist explained the connection of the cause and the additional syndromes or symptoms to the pain disorder (CRPS) Explain ______________________________________________________________________ Using the 1-10 pain scale (one being no pain and 10 being the worst ever, rate your pain at the different time periods. Post injury_________, post 6 months after onset_______, after 1 yr______ after 2 years______ after 3 yrs _______ Has your pain ever stopped?_____________ and for how long? __________________ Have you ever gone into remission? ____________________ Did the CRPS/RSD spread from the primary site? __________ . From where ____________ to where_____________________________________________________________. How long after the initial injury did the spread occur? ______________________ Were you re-injured before the spread occurred? _______________________________, How? ______________________________________________________________ How many doctors/specialists, in total, were or are involved from beginning to the present day in your case? _______________________________________________________ Tell us about your level of pain and symptoms? (Include any of the symptom you experienced such as level of pain, swelling, redness, temperature changes, sweating, movement difficulties, please explain as you would to your doctor. We want to hear from you and in your own words. _____________________________________________________________________________________________________________________________________________________ Rate your level of medical care and describe how helpful the medical system was at the different periods during treatment. Initially pre-diagnosis/ post injury. (Rate between 1-10)_____________________ Explain______________________________________________________________________________________________________________________________________________________ Treatments-(example-how long did it take to get a specific treatment, what tests were done) Rate it (Bet. 1-10)__________________________ Explain____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What Treatments have you had ____________________________________________ List them_____________________________________________________________________ ________________________________________________________________________ What treatments have been refused and why? _______________________________________ Explain________________________________________________________________________ What advice would you give someone who is just hurt and showing symptoms of CRPS/RSD?______________________________________________________________ Of all the doctors involved in your experience with CRPS, in less that 10 words, how would you describe the level of their knowledge about this order? ______________________________________________________________________________________________________________________________________________________ Were any type of tests used on you and claimed to be diagnostic for RSD? If yes, which type)______________________________________________________________________ If this was a work related injury, rate how you were treated. 1 being poorly and 10 being the best. _____________Explain_________________________________________________ were you believed of your pain?______________ If no, provide explanation or a comment to explain _________________________________________________________________ How has having RSD affected your previous income? -Before injury I made ______________ hr or __________ month. -If you have returned to work or will be in the near future, the amount I make now is _________ hr or __________ and the WC provides _____________ month. -Or- I was unable to return to work and the outcome was what percentage of your pre-injury wage? _____________ month. Did you hire a lawyer? _____________ When did you get the lawyer involved? (Please specify if it was related to something specific. Example-after the WC medical examination or an incident).________________________________________________________________ Did you find the lawyer knowledgeable of RSD?______________________________ The approx. amount of money spent on RSD (including wage loss, self paid treatments, self paid medications is approximately $ _____________________ Have you ever experience a negative comment or accusation regarding the level of pain or symptoms you experience? _____ From whom? (Example spouse, doctor, friend) _____________________________________ Was RSD or CRPS accepted on your insurance claim as your final diagnosis?____________ What are your future plans? Indicate one of the following I) Satisfied where I am ___________________ I) Plan to further my education or trade school. Choices. ________________________________ III) Unable to return to work or school _______________________________ IV) must work regardless of how ill I am._____________________ Has CRPS/RSD affected your relationships? _________________ If your doctor, pain specialist or lawyer were very helpful, knowledgeable or an individual you would refer to someone, please add their name and address here. ______________________________________________________________________________________________________________________________________________________ Have you been accused of lying, self creating symptoms or told it was ‘all in your head? By whom_________________________________________ Do you feel like you lost your confidence level or belief system due to pain? ________________________ What 3 things (medication, treatment, copying method or person has been the most helpful for you throughout this entire ordeal? And why? (Please list in order of importance) 1/Thing or person and why_______________________________________________________ 2/thing or person and why________________________________________________________ 3/thing or person and why________________________________________________________ Where you ever exposed to any types of chemical compounds, lived on a farm, lived where air spraying occurred or any other form of chemical type exposure? Describe your personality type. Are you? 1/ ____ calm, cool and collect,2/ _____ hyper, high strung and need things constantly organized, 3/___ mellow-a couch potato 4/______ mostly focused but can go either way. If you are different than these choices, explain here _______________________________________________________ On the day you were injured (or the inciting incident), what mood or type of day would you describe you were having?__________________________________________________ Using the scale of 1-10 with 1 being minimal and 10 being the most, rate how CRPS has altered your life? ______________________ What is your last level of education? __________________________________________ 55. Do you feel you have a good understanding of what this disease is and how it causes your symptoms?__________________ 56. Please add any personal comments. Do you have any ideas, suggestions or comments for The RSD Network Society? __________________________________________________ End of Survey! Thank you so much for your participation! We highly appreciate all information you can provide us on how RSD has affected you. ****************************************************************************** Please fill the questions out fully. Your personal information (name and address) will not be used other than if any additional information is required. We are using this information to create a very in-depth study into CRPS patients and how this disorder affects all of us. Hopefully we can put this information into a book format as an educational tool for both patients with this condition and the medical professions that treat us. If this is possible, would you be interested in purchasing a booklet on RSD ? ____ yes or ____ no. If you have any pictures of your CRPS limb, neurodermatatis (rash in this disorder), or any other symptoms caused by CRPS/RSD, please send copies only of these pictures along with your completed survey. We will not be able to return the picture so please make sure you send only copies you can spare. Signed ______________________________________ Date _______________________

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