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In-House Patient Survey

Completing the survey questions will assist the office staff as they work to find the appropriate information and referrals for your specific situation. 

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First Name *
Last Name *   I am:    
Email *
Street Address *    
Address (cont.)   I am a:
City *  
State/Province *    
Zip/Postal Code *   I learned about TNA from:
Country  
Work Phone    
Home Phone    

The following information to be completed pertaining to the facial pain patient.

How long have you had facial pain?  

What is the current diagnosis of your facial pain?  

Side of face affected:

Area of face affected: 

Type of Pain:  Pick the word or words that describe your pain in each location.

Left Side

Intermittent

Constant

Stabbing

Electric shock

Burning

Aching

Itching

Tingling

Crawling

Pulsing

Pain free

Dull

Sharp

 

Right Side

Intermittent

Constant

Stabbing

Electric shock

Burning

Aching

Itching

Tingling

Crawling

Pulsing

Pain free

Dull

Sharp

 

 

Treatments:      Select T for anything that you have tried in the past.

                             Select C for any current treatment.

Other

Anti-depressants

Anti-anxiety

Anti-viral

Anti-convulsants

Anti-convulsants

Elavil

        Amitriptyline

Pemelor

        Nortriptyline

Valtrex

        Valacyclovir

Gabitril

        Tiagabine

Trileptal

        Oxycarbazepine

Lidoderm Patch

        Lidocaine

Effexor

        Venlafaxine

Zovirax

        Acyclovir

Keppra

          Levetiracetam

Klonopin

        Clonazepam

Zostrix Cream

        Capsaicin

Prozac

        Fluoxetine

Famvir

        Famciclovir

Neurontin

        Gabapentin

Orap

        Pimozide

Baclofen 

        Lioresal

Celexa

        Citalopram

 

Zonegran

        Zonisamide

Topomax

        Topiramate
Steroid Zoloft    

Tegretol/Carbatrol

        Carbamazepine

Anti-inflammatory

        Celebrex/Viox

Tofranil

        Imipramine

 

 

Lamactil

        Lamotrigin

Other

Valium

        Diazepam

    

Depakote

        Depakene

        Valproic Acid

 

Xanax

        Alparzolam

    

Dilantin

        Phenytoin

Narcotics

Other

Anti-depressants

Anti-anxiety

Anti-viral

Anti-convulsants

Anti-convulsants

Darvocet

        Propoxyphone

Demerol

       

Dilaudid

        Hydromorphone HCL

    

Ultracet

        Tramadol

        HCL/Acetam

  

Morphine

      

Methadone

          Dolophine

Oxycontin

        Oxycodone HCL

Percocet

        Oxydone/Acetam

Hydrocodone /

        Acetam

        Vicodin

        Lorcet

Fentanyl Duralgesic

        Patch

        Actiq Sublimaze

MS Contin

        Morphine

        Time release

Other

 

 

Procedures:     Mark the number of times each was done.

                             Mark the side it was on.

MVD (Microvascular Decompression)

Endoscopic MVD

RFR (Radiofrequency Rhizotomy

 

Glycerol Injection

 

Balloon Compression

 

Radiation:  Gamma Knife

 

Radiation:  Cyber Knife

 

Radiation:  Shaped Beam

 

Motor Cortex Stimulation

 

Nerve Sectioning

 

Dorsal Root Entry Zone

 

RFR & Glycerol Combo

 

 

 

 

 

 

 

 

 

 

 

Complementary and Alternative Treatments: 

    Select T for anything that you have tried in the past.

    Select C for any current treatment.

 

Acupuncture

 

Capsacin Cream

       

Chiropractic

 

Upper Cervical

        Chiropractic

Homeopathic

        Medicine

Herbs

 

Vitamins

 

Diet

      

Other Topical

          Solutions

Botox

 

Nerve block

 

 

Laser Therapy

 

 

Electrical Stimulation

        Units (TENS,

        Scenar

Massage

       

       

Biofeedback

        Neurofeedback

 

Other

 

 

 

 

 

Physicians overseeing your care:  Please list below the names and office addresses of any healthcare professionals you recommend. 

 

Primary Care Physician: 

Neurologist:                   

Neurosurgeon:               

Pain Specialist:             

Osteopath:                    

Other:                           

 

 

Are you able to help TNA in our effort to end the pain by:

 

Working with or starting a Support Group?

Being a Telephone Contact Support Person?

Volunteering by

Talking with other patient or family members about your disease or treatment?

 

I would like additional information about:

Thank you for completing this important information. 

Please feel free to contact the National Office by calling 1.800.923.3608 or 352.331.7009 or via email at info@fpa-support.org.

 

 

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