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International Reflex Sympathetic Dystrophy Foundation© "Dedicated To Helping RSD Patients Worldwide"
Eric M. Phillips P.O. Box 1145 Lakeville, Massachusetts 02347 USA Phone: 508-946-9888 Fax: 508-946-3338
Office Hours Monday through Friday 9:00 A.M. to 5:00 P.M. EST
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PRINTABLE RSD SURVEY FORM (Please use this printable version if you are having problems with the on-line version)
International Reflex Sympathetic Dystrophy
Foundation© Dear Friends,
Please mail survey to: Eric M. Phillips If you have any questions or comments about this survey, please feel free to contact me at 508-946-9888.
Name (Optional): E-Mail Address : Age : Sex: M F
1. How did you develop RSD? Animal Bite Cause unknown? Flare up of an old injury Electrical Injury Injury Minor Trauma Surgery Venipuncture (I.V. or I.M. injection / needle injury)
2. When did you develop symptoms of RSD? After Electrical Injury After Heart Attack After Injury After Stroke After Surgery After Venipuncture (I.V. or I.M. injection / needle injury)
3. Where do you have your RSD? Face Internal Organs Left Lower Extremity Left Upper Extremity Right Lower Extremity Right Upper Extremity Total Body (All four extremities)
4. How long have you suffered from RSD?
5. What method was used to help diagnose your RSD? Blood Test Bone Scan Clinical Diagnosis Cold Stress Test CT Scan Doppler EMG MRI Phentolamine (Regitine) Test QSART Test Sympathetic Nerve Block Thermal Stress Test Thermography ( Infrared Thermal Imaging) X-Rays Others (Please describe)
6. How long after injury or surgery were you diagnosed as having RSD? Days: Weeks: Months: Years:
7. Please check any of the following symptoms that you have had
along with your RSD. Abdominal Pain Atrophy Back Pain Bruising Cardiac Disturbance Depression Dizziness Discoloration of Skin Dystonia Facial Pain Falling Spell Hearing Disturbance Headaches Heartburn High Grade Fever Hot Flashes Hyperpathia Hypertension Immune System Disturbance Internal Organ Disturbance Limited Mobility Loss Of Sex Desire (Libido) Low Blood Pressure Low Grade Fever Memory Disturbance Menstrual Irregularity Migraine Headaches Mood Swings Movement Disorder Muscle Contractions of the Fingers or Toes Muscle Spasm Osteoporosis Pelvic Pain Rapid Hair Growth Rapid Hair Loss Rapid Nail Growth Rapid Nail Loss Rash Severe Fatigue Shoulder Hand Syndrome Skin Lesion's (Skin Ulcers) Sleep Disturbance Stomach Ulcers Sweating Swelling (Edema) Tremor Vasoconstriction Visual Disturbance Weight Gain Weight Loss Others
8. Please check any of the following treatments listed below, that you have
tried. Please place one of the following letters (i, d, s, f
)next to your answer if your RSD symptoms increased or
decreased your RSD symptoms and if these treatments were
a success or failure in your
quest for pain relief. If not sure please place the letter (u)
for "Undecided" next to your selection.
Others (Please describe)
9. Please check any of the following treatments listed below,
that you have tried. Please place one of the following letters (i, d, s,
f)next to your answer if your RSD symptoms increased
or decreased your RSD symptoms and if these treatments
were a success or failure in
your quest for pain relief. If not sure please place the letter (u)
for "Undecided" next to your selection. PLEASE NOTE * (GENERIC NAME) Others (Please describe)
11. If you are currently taking Methadone for your RSD, have you
had any of the following side effects? (If you are
not taking Methadone please skip to question 17). Bronchopneumonia Cardiac Dysrhythmia Confusion Dizziness High Toxicity Level Narcolepsy (Tendency To Fall Asleep) Pulmonary Edema Respiratory Depression (Breathing Problems) Sleep Apnea (Temporary Cessation Of Breathing During Sleep)
12. While taking Methadone have you had any blood testing done to check the toxicity levels of the Methadone in your system? Y N
14. How long have you been taking Methadone? Days: Weeks: Months:Years:
15. How many milligrams of Methadone do you take each day?
16. Has Methadone increased or decreased your RSD pain?
17. Prior to taking Methadone did you ever take Morphine or M.S. Contin? Y N
19. How many hours a night do you sleep?
20. How is your ability to concentrate on things that you feel are important to you? Good Moderate Poor
21. Do you ever have a feeling of a electrical jolt in your affected extremity? Y N
22. Have you had problems with your balance since developing RSD? Y N
23. Have you ever been told by any doctor that your RSD is in your head and that you are crazy? Y N
24. Has your RSD spread since the time of onset? Y N
25. If your RSD has spread from the time of onset, please tell us how long that it took for your RSD to spread. Days:Weeks:Months:Years:
26. Did your RSD spread after surgery? Y N
27. Did your RSD spread after ice application? Y N
29. Did your RSD spread after application of cast? Y N
31. Have you developed any type of deformity or contractures in your affected extremity? Y N
32. If you have developed any type of deformity or contractures, please tell us how long it took for the deformity or contractures to start after the onset of your RSD. Days:Weeks:Months:Years:
33. Please check any of the following places where you have your deformity or contractures.
Left Hand Left Wrist Left Arm Left Elbow Left Shoulder Left Toes Left Foot Left Ankle Left Leg Left Knee Left Hip Right Fingers Right Hand Right Wrist Right Arm Right Elbow Right Shoulder Right Toes Right Foot Right Ankle Right Leg Right Knee Right Hip
34. Have you had any amputations of your affected RSD extremities or digits? Y N
35. If an amputation was performed, please tell us below what extremity or digit was amputated.
37. On average, how many points (zero to 10) pain improvement did you have after amputation? Please circle (0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10).
38. Since the time you were diagnosed with RSD, have you ever been diagnosed with any of the following disorders:
Bursitis Carpal Tunnel Syndrome Chronic Fatigue Syndrome (CFS) Cervical Spondylosis Clonus Diabetes Dystonia Fibromyalgia Syndrome (FMS) Frozen Shoulder Syndrome Lupus Migraine Headaches Multiple Sclerosis (MS) Myofacial Pain Syndrome Phantom Limb Pain (PLP) Scleroderma Spinal Disc Disease Tarsal Tunnel Syndrome Tendonitis Thoracic Outlet Syndrome (TOS) TMJ Trigeminal Neuralgia Ulnar Nerve Entrapment Others
39. Please check any of the following, if they increase your RSD pain. Alcohol Chocolate Cold Emotions Foods Heat Humidity Stress Others
40. Are there others in your family who also suffer from RSD? Y
N
42. How many Spinal Cord Stimulators have you had implanted?
43. Have you had any of the following complications with your
Spinal Cord Stimulator: Attacks of Falling Attacks of Paralysis Infections Increased Pain Jerking Movement of Extremities Movement Disorder Movement of Electrodes and Lead Wires Spread of RSD Stimulator Not Working Tremor Weakness of Extremities Others
44. On average, how many points (zero to 10) pain improvement did you have with the (SCS) Spinal Cord Stimulator? Please circle (0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10).
46. Have you had any of the following complications with your Infusion Pump. Increased pain Infection Headaches Leakage Pump not working Scar formation around the pump Spread of RSD Swelling of extremities Vomiting or Intolerance of pump Others
47. Do you take pain medication by mouth in addition to morphine in the pump? Y N (Please describe)
48. On average, how many points (zero to 10) pain improvement did you have with the pump? Please circle (0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10).
49. How long did your SCS or Infusion pump work before you started to have complications? Days:Weeks:Months:Years:
50. Have you had a Surgical or Chemical Sympathectomy? Y N
52. Have you had any of the following complications after having the Surgical or Chemical Sympathectomy performed? Horner's syndrome Increased pain Infection Spread of RSD Others
53. How long did your Surgical or Chemical Sympathectomy give you pain relief before you started to have complications? Days: Weeks: Months: Years:
54. On average, how many points (zero to 10) pain improvement did you have
after Surgical or Chemical Sympathectomy? Please
circle (0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10). 55. Please check any of the following types of Nerve Blocks that were used to
treat your RSD. Axillary Nerve Block Bier Block Brachial Plexus Block Epidural Block Lower Lumbar Sympathetic Nerve Block Paravertebral Nerve Block Stellate Ganglion Nerve Block Others
56. How many Nerve Blocks have you had since you started your treatment for RSD.
58. How many hours, days, weeks, or months did you have relief after having
any of the following types of nerve blocks:
59. How is your activity level after having a Nerve Block?
60. Have you had any complications from having a Nerve Block?
61. If your RSD developed from a Venipuncture, please check one of the
following procedures that caused your RSD. (If
this question does not pertain to you please skip to question 62) Blood Sampling Flu Shot Hepatitis B Injection Intramuscular Injection I.V. Injection ( Intravenous line) I.V. Injection (Intravenous of medication) Needle Injury Tetanus Shot Others
62. When did you experience pain from your venipuncture injury? After Venipuncture During Venipuncture After Intramuscular Injection During Intramuscular Injection Days Weeks Months Years
63. Have you had any of the following complication from your venipuncture injury?
Skin Lesions Skin Rashes Swelling Trophic Ulcers Others
64. Do you ever have any of the following symptoms on your skin in the RSD
affected extremity? Bruising Discoloration Skin Lesions Skin Rashes Skin Ulcers Others
65. Do you ever have sudden attacks of falling? Y N
66. If you do have sudden attacks of falling, please tell us how often.
67. Please tell us below what your occupation was at the time of onset.
68. Are you still able to work? Y N
69. How many doctors did you see before you were diagnosed with RSD?
70. If your RSD was caused by surgery , how long after surgery were you diagnosed as having RSD? Days: Weeks: Months: Years:
71. What type of doctor diagnosed your RSD?
72. Has your RSD ever gone into remission? Y N
73. If your RSD has gone into remission, please tell us at what stage of RSD you were in at the time of remission. Stage I Dysfunction (Burning pain)
74. If your RSD did go into remission, please tell us how long you were
75. Please tell us below, what treatment or method helped your RSD go into remission.
76. Has your RSD gone into remission more than once since your onset of RSD? Y N
78. Was your RSD aggravated after the application of ice? Y N
79. Was your RSD aggravated after the application of a cast? Y N
80. Do you suffer from any of the following disorders other than RSD: Cerebral Palsy (CP) Diamond Gardner Syndrome (Bruising) Ehrler Danlos Syndrome Epilepsy Fabry's Disease Herpes Zoster (Shingles) Lupus Lyme Disease Menier's Disease Multiple Sclerosis (MS) Muscular Dystrophy (MD) Parkinson Trigeminal Neuralgia (Tic Douloureux) Other
81. If your RSD developed from an Electrical Injury, please check one of the following injuries that caused your RSD. Electrical Burn Electrical Shock High Voltage (600-1,000 volts or higher / A.C.= Alternating Current) Lightning Strike( D.C.= Direct Current) Low Voltage (110 to 240 volts / A.C.= Alternating Current)
83. How long after your electrical injury were you diagnosed as having RSD?
84. Was your RSD caused by a chemical burn? Y N
85. If your RSD was caused by a chemical burn, please briefly describe what type of chemical caused the burn.
86. How long after your chemical burn were you diagnosed as having RSD? Hours: Days: Weeks: Months: Years:
87. Was your RSD caused by an infection? Y N
88. Please describe what type of infection caused your RSD.
89. How long after developing your infection were you diagnosed as having
RSD?
90. Have you developed any herniated disc since you developed your RSD? Y N
91. Please check any of the following assistive devices that you use. Braces Cane Crutches Electric Scooter Walker Wheelchair
92. How long have you been using these assistive devices?
93. Has there been any one doctor or pain clinic that has had any success in treating your RSD? Y N
94. If your RSD was successfully treated, please list below the name and address of your doctor or the pain clinic that treated you.
95. Would you recommend your doctor or the pain clinic that you go to for treatment to other RSD patients? Y N
96. Do you have a good support system with your family and friends? Y N
97. Do you find that your family and friends have a hard time understanding what you are going through since you developed RSD? Y N
98. Was the Internet helpful to you during your quest to obtain information regarding RSD? Y N
99. What State or Country do you live in?
100. Do you belong to an RSD Support Group? Y N
©1997 Eric M. Phillips, International Reflex Sympathetic Dystrophy Foundation
The material on the IRSDF Homepage and all its
associated, linked or reference pages is for informational and education
purposes. It is not meant to take the place of your
physician. Before starting, changing, or stopping any treatments or medicines
consult your physician.
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