Form.doc

TRIGEMINAL NEURALGIA ASSOCIATION
FACE PAIN SURVEY
SECTION I: CONTACT INFORMATION
First Name:

SECTION II: PRESENT DIAGNOSIS

(Some people have more than one disorder. Check any that you’ve had and indicate if you are pain free now).

SECTION III: FAMILY AND PERSONAL HISTORY

Has anyone in your family had any of the following conditions? (If no, please skip to your medical history)

SECTION IV: YOUR MEDICAL HISTORY

Have you ever been told by a doctor that you have any of the following? (check all that apply)
Before your face pain developed, did you have a root canal or other dental therapy? If “Yes”, how many: _____days / _____weeks / _____ months before your face pain? When did pain first develop in your face? Year: ________ Your Age Then: ________ Please describe your pain when it first started: (check all that apply) Type of Pain:
How Often:
Which Sides Were Affected:
Did Pain Awaken You From Sleep:
Please write in the intensity for each area affected: (on a scale of 1 = Slight Discomfort, to 10 = Very intense, overwhelming pain) If “Yes”, please describe your pain: (check all that apply) Type of Pain:
How Often:
Which Sides Are Affected:
Does Pain Awaken You From Sleep:
Please write in the intensity for each area affected: (on a scale of 1 = Slight Discomfort, to 10 = Very intense, overwhelming pain)
SECTION V: FINDING HELP FOR YOUR DISORDER

How long did it take to get a diagnosis?
What kinds of caregivers did you see before you were diagnosed with TN, ATN, GN, or ATFP? (check “X” for all that apply) What incorrect diagnoses did you receive? (Please check all that apply – SKIP if you had no problems getting a diagnosis.) Abscessed tooth (root canal or extraction) What kind of caregiver first told you that your symptoms might be related to TN, ATN, GN, or ATFP?
SECTION VI: DRUG TREATMENTS YOU RECEIVED

Write in how much of your pain was relieved by each drug you’ve used: 1= No Relief, 2= Partial Relief, 3= Pain Gone
Enter dates most frequently used. If you didn’t use a drug, leave blank.
Relief
List your current or most recent medications: For the most recent medications, if you had side effects, what were they? Write in the severity of each effect, on a scale of 1=mild, 2=moderate, 3=severe, 4=very severe Have you discontinued medications because of side effects? If Yes, which drugs: Satisfaction with most SECTION VII: SURGICAL TREATMENTS
If you had a surgery more than once, please indicate how many times. Give the most recent date you had that
kind of surgery. For side effects, indicate 1= mild, 2= mo derate, 3=severe, 4=very severe. Please indicate how
long relief lasted.
Why did you select your most recent surgery? Doctor recommended as best alternative for pain relief I heard of another patient’s successful outcome Did you feel pressured by your doctor to have the recommended surgery? For your most recent surgical treatment, if you had side effects, what were they? Write the severity for each you had: 1=mild, 2=moderate, 3=severe, 4=very severe. Leave blank if effect did not occur
SECTION VIII: RECOMMENDATIONS

Would you recommend a physician who treated you to other face pain patients?
If Yes, please give physician information: First Name:
SECTION IX: COMMENTS

Return completed survey to:
Trigeminal Neuralgia Association
2801 SW Archer Road, Suite C
Gainesville, FL 32608

Source: http://www.tna-support.org/newlook/register_files/survey/facepainsurvey.pdf