Print out and fill in the Questionnaire below before visiting one of the clinics listed on the RSD Clinics page. This will help doctors more accurately diagnose your ailment.


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 Canadian 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.

If you agree that the Canadian RSD Network Society can use the information
provided on the study or pictures provided please sign the release form
below and mail to the Canadian RSD Network Society.

I, _______________________________________, give permission for all of the
above information (not including my name, telephone number or address) to be
used within this survey by the Canadian RSD Network for the creation of any
medical textbook, statistical information or other educational purposes.
Pictures
_____Yes, I have included pictures which I also give permission for the
Canadian RSD Network to use for the above purposes.

Signed ______________________________________ Date _______________________

Other Health Related Resources:

www.posturalhypertension.com

www.mentalabuse.net – Mental Abuse Help

Toothwhiteningcost.com