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
Where is the injury? (example left elbow
My injury occurred on (date) _____________________________________________
pain began how long after injury?(
days/weeks/months)___________________________ First diagnosis of
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
Why do you believe it is CRPS/RSD and your doctor does not?
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:
Work related injury________________
Describe the ‘initial’ symptoms you
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?
Are you CRPS Type 1 (RSD) or Type II (RSD with proven nerve
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
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
How long after the initial injury did the spread occur?
Were you re-injured before the spread occurred?
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)_____________________
Treatments-(example-how long did it take to get a specific treatment,
what tests were done) Rate it (Bet. 1-10)__________________________
What Treatments have you had
What treatments have been refused and why?
What advice would you give someone who is just hurt and showing symptoms of
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.
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 _____________
-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
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
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
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
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
2/thing or person and
3/thing or person and
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
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
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.
_____Yes, I have included pictures which I also give permission for the
Canadian RSD Network to use for the above purposes.
Signed ______________________________________ Date _______________________
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