Name (Optional):

E-Mail Address :

Age:

Sex:  M F

Please note: It may be necessary to hold your Ctrl key down while clicking with your mouse to select multiple options.

1. How did you develop RSD? Please Choose Animal Bite Cause unknown? Electrical Injury Flare up of an old injury Injury Minor Trauma Surgery Venipuncture (I.V. or I.M. injection / needle injury)                                (If other: Please tell us how you developed your RSD)

2. When did you develop symptoms of RSD?

Please Choose After Electrical Injury After Heart Attack After Injury After Stroke After Surgery After Venipuncture (I.V. or I. M. injection / needle injury)

4. How long have you suffered from RSD?

8. Please check any of the following treatments listed below, that you have tried. Please select one of the following answers if these treatments increased or decreased your RSD symptoms and if these treatments were a success or failure in your quest for pain relief. If not sure select "Undecided".
 

Acupuncture Please Choose Increased Decrease Success Failure Undecided  

Amputation Please Choose Increased Decrease Success Failure Undecided         

Application of Heat Please Choose Increased Decrease Success Failure Undecided

Application of Ice Please Choose Increased Decrease Success Failure Undecided       

Arthroscopy Please Choose Increased Decrease Success Failure Undecided

Bio-Feed Back Please Choose Increased Decrease Success Failure Undecided    

Carpal Tunnel Surgery Please Choose Increased Decrease Success Failure Undecided       

Chemical Sympathectomy Please Choose Increased Decrease Success Failure Undecided  

Chiropractor Please Choose Increased Decrease Success Failure Undecided  

Cingulotomy Please Choose Increased Decrease Success Failure Undecided      

Cordotomy Please Choose Increased Decrease Success Failure Undecided  

Cryosurgery Please Choose Increased Decrease Success Failure Undecided

Disc Surgery Please Choose Increased Decrease Success Failure Undecided

Exploration  Please Choose Increased Decrease Success Failure Undecided

Fusion Surgery Please Choose Increased Decrease Success Failure Undecided    

Homeopathy Please Choose Increased Decrease Success Failure Undecided

Hydrotherapy Please Choose Increased Decrease Success Failure Undecided     

Hypnosis Therapy Please Choose Increased Decrease Success Failure Undecided

Infusion Pump Please Choose Increased Decrease Success Failure Undecided      

I.V. Mannitol Please Choose Increased Decrease Success Failure Undecided   

Ketamine Treatment Please Choose Increased Decrease Success Failure Undecided

Knee Surgery Please Choose Increased Decrease Success Failure Undecided  

Laser Surgery Please Choose Increased Decrease Success Failure Undecided

Magnet Therapy Please Choose Increased Decrease Success Failure Undecided  

Micro Surgery Please Choose Increased Decrease Success Failure Undecided  

Nerve Graft Please Choose Increased Decrease Success Failure Undecided

Neurectomy Please Choose Increased Decrease Success Failure Undecided

Occupational Therapy (O.T.) Please Choose Increased Decrease Success Failure Undecided

Phentolamine Test Please Choose Increased Decrease Success Failure Undecided

Physical Therapy (P.T.) Please Choose Increased Decrease Success Failure Undecided

Psychotherapy Please Choose Increased Decrease Success Failure Undecided

Radiofrequency Treatment Please Choose Increased Decrease Success Failure Undecided

Removal of Neuroma Please Choose Increased Decrease Success Failure Undecided

Rhizotomy Please Choose Increased Decrease Success Failure Undecided

Rib Resection Please Choose Increased Decrease Success Failure Undecided

Rotator Cuff Surgery Please Choose Increased Decrease Success Failure Undecided

Spinal Cord Stimulator Please Choose Increased Decrease Success Failure Undecided

Sympathectomy (Surgical) Please Choose Increased Decrease Success Failure Undecided

Sympathetic Nerve Block Please Choose Increased Decrease Success Failure Undecided

Tarsal Tunnel Surgery Please Choose Increased Decrease Success Failure Undecided

Tendon Release Please Choose Increased Decrease Success Failure Undecided

TENS Unit Treatment Please Choose Increased Decrease Success Failure Undecided

Ulnar Nerve Release Please Choose Increased Decrease Success Failure Undecided

Ultrasound Please Choose Increased Decrease Success Failure Undecided

Others (Please describe)

10. Please list below the names and amount of the medications that you are currently taking.

21. Do you ever have a feeling of a electrical jolt in your affected extremity? Please Choose Yes No                                                                                                                           

22. Have you had problems with your balance since developing RSD?   Please Choose Yes No                                                                                                                             

23. Have you ever been told by any doctor that your RSD is in your head and that you are crazy?    Please Choose Yes No                                                                                                                         

24. Has your RSD spread since the time of onset?    Please Choose Yes No                             

25. If your RSD has spread from the time of onset, please tell us how long that it took for your RSD to spread.   

26. Did your RSD spread after surgery?  Please Choose Yes No                                             

27. Did your RSD spread after ice application?     Please Choose Yes No                                

28. If your RSD did spread from surgery, please describe below what type of surgery you had.

29. Did your RSD spread after application of cast?    Please Choose Yes No                    

30. At the time of onset was the skin temperature in your affected extremity hot or cold? Please Choose Hot Cold

31. Have you developed any type of deformity or contractures in your affected extremity? Please Choose Yes No                                                                                                   

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.                                                                          

39. Please check any of the following, if they increase your RSD pain. Please Choose Alcohol Chocolate Cold Emotions Foods Heat Humidity Stress
Others:

40. Are there others in your family who also suffer from RSD? Please Choose Yes No    
If so, please tell us how many family members also suffer from RSD.

41. If you have had a Spinal Cord Stimulator implanted, please tell us if the SCS has increased or decreased your RSD pain. Please Choose Increased Decreased

42. How many Spinal Cord Stimulators have you had implanted?

46. Have you had any of the following complications with your Infusion Pump. Please Choose Increased Pain Infection Headaches Leakage Pump not working Scar formation around the pump Spread of RSD Swelling of the extremities Vomiting or Intolerance of pump Others:

47. Do you take pain medication by mouth in addition to morphine in the pump?   Please Choose Yes No (Please describe):

48. On average, how many points (zero to 10) pain improvement did you have with the pump?  Please Choose 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?  

50. Have you had a Surgical or Chemical Sympathectomy?     Please Choose Yes No    

51. If a Surgical or Chemical Sympathectomy was performed did it increase or decrease your RSD pain. Please Choose Increase Decrease

52. Have you had any of the following complications after having the Surgical or Chemical Sympathectomy performed? Please Choose Horners Syndrome Infection Spread of RSD Increased pain Others:

53. How long did your Surgical or Chemical Sympathectomy give you pain relief before you started to have complications?   

54. On average, how many points (zero to 10) pain improvement did you have after Surgical or Chemical Sympathectomy?
Please Choose 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. Please Choose Axillary Nerve Block Bier Block Brachial Plexus Block Epidural Block Lower Lumbar Sympathetic Nerve Block Stellate Ganglion Nerve Block Others:

56. How many Nerve Blocks have you had since you started your treatment for RSD.

57. Please tell us if your pain increased or decreases after having any of the above mentioned nerve blocks. Please Choose Increase Decreases

58. How many hours, days, weeks, or months did you have relief after having any of the following types of nerve blocks:

58a. Axillary Nerve Block:   

58b. Bier Block:  

58c. Brachial Plexus Block:   

58d. Epidural Block: 

58e. Lower Lumbar Block:  

58f. Paravertebral Block:  

58g. Stellate Ganglion Block: 

59. How is your activity level after having a Nerve Block? Please Choose Excellent Good Moderate Poor

60. Have you had any complications from having a Nerve Block?
(Please describe)

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) Please Choose Blood Donation Blood Sampling Flu Shot Hepatitis B injection Intraamuscular 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? Please Choose 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? Please Choose Bruising 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? Please Choose Bruising Discoloration Skin Lesions Skin Rashes Skin Ulcers Others:

65. Do you ever have sudden attacks of falling?   Please Choose Yes No

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?    Please Choose Yes No

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?   

71. What type of doctor diagnosed your RSD?

72. Has your RSD ever gone into remission?   Please Choose Yes No                                    

73. If your RSD has gone into remission, please tell us at what stage of RSD you were in at the time of remission. (Please see the list of examples below):

Stage I -Dysfunction (Burning pain)

Stage II -Dystrophy (Skin and nail changes and edema)

Stage III -Atrophy (Disuse)

Stage IV -(Disturbance of immune system. Lack of response to treatment)

74. If your RSD did go into remission, please tell us how long you were
in remission.   

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?     Please Choose Yes No                                                                                                           

77. What helps you more heat or cold or both? Please Choose Heat Cold

78. Was your RSD aggravated after the application of ice? Please Choose Yes No                 

79. Was your RSD aggravated after the application of a cast?  Please Choose Yes No        

80. Do you suffer from any of the following disorders other than RSD: Please Choose Bells Palsy Cerebral Palsy (CP) Diamond Gardner Syndrome (Brusing) Ehrler Danlos Syndrome (EDS) Epilepsy Fabrys Disease Herpes Zoster (Shingles) Lupus Lyme Disease Meniers 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. Please Choose 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)

82. Was your electrical injury an industrial or household injury? Please Choose Industrial Household          (Please briefly describe below what happen during your electrical injury.)

83. How long after your electrical injury were you diagnosed as having RSD?
 

84. Was your RSD caused by a chemical burn?   Please Choose Yes No                                  

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?               

87. Was your RSD caused by an infection?    Please Choose Yes No                               

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?   Please Choose Yes No                                                                                                                      

91. Please check any of the following assistive devices that you use. Please Choose Braces Canes 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?      Please Choose Yes No                                                                                                                

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?   Please Choose Yes No                                                                                                      

96. Do you have a good support system with your family and friends?     Please Choose Yes No                                                                                                                       

97. Do you find that your family and friends have a hard time understanding what you are going through since you developed RSD?   Please Choose Yes No                                                       

98. Was the Internet helpful to you during your quest to obtain information regarding RSD? Please Choose Yes No                                                                                                                              

99. What State or Country do you live in?

100. Do you belong to an RSD Support Group? Please Choose Yes No                                     

©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.
Eric M. Phillips, and Associates will not be held liable for any damage or loss as a result of information provided on this page or associated documentation. Again, this WEBSITE is simply published as an information source and should not be used to treat or make judgments on RSD. All material owned by others, that is distributed or published on this website, disk media, facsimile or copied through electronic or photographic means has been done so with the permission of the owner or author. Any and all material published in error, will be immediately removed or corrected upon notification of such. The IRSDF organization title known as the "International Reflex Sympathetic Dystrophy Foundation" and all associated material on this website may not be copied, reproduced or quoted without expressed written permission from the owner;  Copyright  ©1996-2012 Eric M. Phillips- Last Update 5/8/2003