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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
PIETRO SALVAGGIO Born in Turin, he starts studying piano with Prof.ss Walli Peroni, and then in Bologna with Maestro Alfredo Speranza, where he finishes his studies getting full marks. He gets his diploma in composition after having studied with Prof.ssa Matilde Capuis, and studies conducting with M° C. Damevino. He attends many national and international piano competitions always positi