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>
> Please copy and print out. Ask your pain specialists to keep at hand for
RSD
> patients, your gp for RSD patients or any other individual or doctor who
would
> see RSD/CRPS patients. INFO@...
> __________________________________________
>
> Complex Regional Pain Syndrome Survey
> (RSD Type I and Causalgia Type II)
>
> This survey is conducted by the Canadian RSD Network Society. All personal
> information gathered is confidential. We appreciate you taking the time to
> help make a difference in the current information about Reflex Sympathetic
> Dystrophy.
>
> HOW TO DO THE SURVEY
>
> Please print this survey and use additional paper as needed. We want this
> information to be exactly how RSD/CRPS has affected you and in your own
words.
> Please print clearly or type. Your pictures of your CRPS/RSD limb are also
> greatly needed and appreciated. Feel free to make copies of this survey
> and provide them in your doctors, pain specialists, physiotherapist or
> lawyer's office. Ask them to get involved by merely making patients aware
of
> the survey and doing their part in this effort by making copies for those
that
> have this disorder.
>
> *Please fill in your email or telephone number on the top of each sheet of
> paper as well as any picture/s you wish to send to us for our research
> purposes.
> Once completed, return via email to info@...
> or mail to:
> RSD Survey, CANADIAN RSD NETWORK SOCIETY
> Box 367 Surrey Main Post, Surrey, BC, Canada V3T 5B6
> We would like to thank you for your participation
> --------------------------------------------------------------------------
-----
> ----------------------------
> Survey
>
> 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
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