1. Name (optional):
2. Email (required):
3. Sex:
   female
   male
   
4. Ethnicity:
   White/Caucasian
   Hispanic
   African American
   Pacific Islander
   Asian
   Native American
   Other:
   
5. Location:
   USA
   Other:
   
6. Current Age:
   0-10
   11-20
   21-30
   31-40
   41-50
   51-60
   61-70
   71-80
   81-90
   90+
   
7. Are you left or right handed?
   left
   right
   
8. Do you have RSD?
   yes
   no
   unsure
   
9. Age at diagnosis of RSD :
   
10. Where do you have RSD?
    hand
    foot
    arm
    leg
    head
    neck
    pelvis
    bodywide
    other:
    don't have RSD
    
11. Do you have or have you had post traumatic stress disorder from any cause (abuse, war, etc.)?
    yes
    no
    
12. Do you have a family history of depression, PMDD, obsessive compulsiveness, bulimia, anorexia, serotonin lowered issues or other disorders treated with SSRI's?(i.e.Prozac, Paxil, Zoloft)
    yes
    no
    
13. Were you more than 2 weeks premature at birth?
    yes
    no
    
14. Were you more than 4 weeks premature at birth?
    yes
    no
    
15. Was your mother over 30 when she gave birth to you?
    yes
    no
    
16. Was your mother over 35 when she gave birth to you?
    yes
    no
    
17. Were you significantly overweight when you developed RSD?
    yes
    no
    don't have RSD
    
18. Were you abused at any time in your life?
    yes
    no
    
19. Did you have adult onset chicken pox and/or measles?
    yes
    no
    Unsure
    if yes, at what age:
    
20. Do you have family history of dupryens syndrome?
    yes
    no
21. Do you have a lowered immune system now?
    yes
    no
22. Did you have a lowered immune system prior to RSD?
    yes
    no
    don't have RSD
    
23. Did you have a lowered immune system after the onset of RSD?
    yes
    no
    don't have RSD
    
24. Do you have a thyroid disorder?
    yes
    no
    if yes:
    choose one hyper hypo
    
25. Did you have prior injuries to afflicted area?
    1
    2
    3-5
    5+
    none
    don't have RSD
    
26. If your RSD has spread beyond the original location did it:
    spread for no reason
    spread from sympathectomy
    spread to "mirror" the original location
    spread due to surgery
    spread due to SCS (Spinal Cord Stimulator)
    spread due to blocks
    spread due to another injury
    spread after another medical treatment
    spread due to acupuncture
    unknown type
    other:
    don't have RSD
    
27. Which symptoms are most problematic? (check all that apply)
    burning
    sweating
    coldness
    hypersensitive
    deep in bone pain
    low imm.
    spasms
    shaking
    nothing
    don't have RSD
    
28. Have you had SCS (Spinal Cord Stimulator)?
    yes
    no
    
29. Have you had morphine pump?
    yes
    no
    
30. Have you had topical medications?
    yes
    no
    
31. Have you had nerve blocks?
    yes
    no
    
32. Have you had spinal blocks?
    yes
    no
    
33. Have you had epidural blocks?
    yes
    no
    
34. Did any of these (22-27) cause spreading?
    yes
    no
    
35. Did your RSD improve during any of these?
    SCS (Spinal Cord Stimulator)
    morphine
    topical
    nerve block
    spinal blcok
    epidural
    sympathetctomy
    don't have RSD
    
36. Did your RSD worsen with any of these?
    SCS (Spinal Cord Stimulator)
    morphine
    topical
    nerve block
    spinal blcok
    epidural
    sympathetctomy
    don't have RSD
    
37. Have you been pregnant at any point during RSD?
    yes
    no
    if yes: did your symptoms improve or worsen
    choose one improve worse
    don't have RSD
38. Are you now, or were you previously, a workaholic or more active than others your age?
    yes
    no
    
39. If you have RSD now, were you a workaholic or more active than others your age prior to the onset?
    yes
    no
    don't have RSD
40. Does anyone in your immediate family have a history of migraines?
    yes
    no
    if yes: are they more severe or more numerous since developing RSD?
    choose one more severe more numerous don't have RSD
    
41. Do you have any sensitivity to drugs?
    yes
    no
    
42. Do you have a history of migraines?
    yes
    no
    
43. Do you have asthma?
    yes
    no
    if yes, is it more since RSD?
    choose one yes no don't have RSD
    
44. Do you have allergies?
    yes
    no
    if yes, is it more since RSD?
    choose one yes no don't have RSD
    
45. Prior to RSD what was your tolerance of alcohol?
    high
    some
    low
    none
    didn't drink
    don't have RSD
    
46. Would you classify your pre RSD self as Type A Personality?
    yes
    no
    don't have RSD
    
47. If you have RSD now, were you someone who prior to its onset put others wants and needs before your own?
    always
    often
    sometime
    rarely
    never
    don't have RSD
    
48. If you do not have RSD, are you someone who puts others wants and needs before your own?
    always
    often
    sometime
    rarely
    never
    
49. How self confident are you?
    very self confident
    somewhat self confident
    occasionally self confident
    rarely self confident
    never self confident
    
    
50. How would you rank your self esteem?
    excellent
    above average
    average
    below average
    awful
    
    
51. Comments or Feedback (optional):