Question 1: How long
have you had chronic pain?
Question 2: Do you have
pain in a) only 1 area of the body, or b) more than 1 area of the body - i.e., in 2 or more separate areas with a non-painful
area in between? (Select a or b).
Question 3: Which of
the following areas are painful: a) head, b) lower back, c) knee, d) shoulder, e) hip, f) foot, g) back of leg, h) other
area? (Select all that apply)
Question 4: In which
part of the body is the pain most troublesome (Select one only from a-h above)?
Question 5: Is this
most troublesome pain best described as a) sharp, dull, aching or stabbing, b) numb, pins & needles, burning, or like
electric shocks, or c) neither a or b? (Select a, b or c).
Question 6: Do you have
pain ABOVE THE KNEE in the colored sciatica leg areas to the right (you can have pain in the colored areas at or below the
knee, but to select a color you must also have pain for that color above the knee): a) green, b) red, c) blue? (Select all that apply).
Question 7: (Optional Information – If you can’t provide it all, don’t worry – just send the responses
to Questions 1-6 and anything you want to provide for Question 7. A sample email response is shown below). Please provide
your Age, Sex, and the State you live in. If you wish, add up to 6 lines of additional information about your pain. Save the
picture of the whole human body on the right to your hard disk (right click on the picture with your mouse, and
select "Save Picture As"). Then print out the picture, draw an outline of each of your painful areas, and put an "X" inside
each painful area to indicate where your pain is worst. Please mail your drawing together with a copy of the email you send
us to: Chronic Pain, TMT Inc., 196
E 75th Street, New York, NY 10021,
USA (or you can scan the image into your computer, save it as
a JPG file and attach it to your email response sent to masterdocs@hotmail.com). The information on the drawing will allow us to more accurately match up your pain with the pain specialist diagnoses.
SAMPLE EMAIL
RESPONSE:
To: masterdocs@hotmail.com
Subject: Chronic Pain
Text:
Question 1: 2.5 years
Question 2: b
Question 3: b, g
Question 4: g
Question 5: b
Question 6: b
Question 7: 55, Male, Iowa