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Questionnaire Part Two

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Please just confirm first whether or not you have already completed Part 1 of the questionnaire.Yes/No.

If No, are you happy to fill that part in too...we can send it to you?

The first 10 questions are specifically about pain. We are looking at pain over the past week or so.

Section 1

1.    What is the average level of your pain on a scale of 1-10, 0= no pain, 10= worst pain imaginable?
2.    what is the worst level of pain you have had in the past week?
3.    where is your pain (include as many as you need to):  (a) back (b) neck (c) head (d) limbs (e) chest (f) abdomen (g) pelvis
4.    what type of pain is it (include all relevant descriptions)  : (a) sharp (b) stabbing (c) burning / hot+cold together (d) aching (e) other (please specify)
5.    do you have (a) pins & needles (b) numbness (c) pain in a numb area (d) pain with light touch (e) odd sensations e.g. insect bites, electric shock (f) muscle cramps? (include all relevant)
6.    do you have any of the following associated with your pain: (a) shortness of breath (b) palpitations (c) less/more awareness of bladder sensation (d) sensitivity to light/ noise/ startle easily (e) anxiety/panic (f) sweating (g) weakness?
7.    do you have fatigue? If so, on a scale of 1-10 (0=no fatigue, 10= worst you could imagine) what level do you experience?
8.    does sleep affect your sleep? If so, do you have (a) difficulty falling asleep, (b) wake because of pain (c) wake early in the morning? (include all that apply to you)
9.    does pain limit what you can do (activities) E.g. (a) sitting (b) standing (c) walking (d) lifting (e) bending? Are you wheelchair or bedbound?
10.    does pain make you (a) irritable (b) tearful (c) depressed (d) anxious (e) have difficulty concentrating (f) have memory difficulties?

Section 2

Here are some questions about other symptoms that may be related to arachnoiditis:

1)    bladder dysfunction (needing to go urgently, inability to initiate passing water, incomplete emptying, incontinence)
2)    bowel dysfunction: incontinence, loss of rectal sensation
3)    sexual dysfunction
4)    muscle spasms/cramps
5)    weakness/paralysis
6)    balance problems
7)    excessive sweating
8)    other (please specify)

Section 3

The next questions are about other general health problems.Please answer Yes or No. If you answer Y (yes) to a question, please put some brief details, including how long you have had the problem.

1.    do you have any difficulty breathing?
2.    do you have any heart problems?  
3.    do you have any bowel problems, e.g constipation or indigestion?
4.    do you have any liver disease?
5.    do you have any kidney disease?
6.    do you have any joint problems?
7.    do you have any endocrine disease e.g. diabetes, thyroid?
8.    do you have any skin problems? In particular do you have psoriasis/eczema?
9.    do you have any hearing or sight problems?
10.    do you have any problem with chronic infections/immune deficiency?
11.    do you have cancer?
12.    if you are a woman, have you had any gynae problems such as irregular periods?
13.    do you have any psychiatric or emotional problems?

Section 4

The following questions relate to your past medical history. This does NOT include arachnoiditis or spinal surgery etc. which was included in Part 1 of the questionnaire.

1.    Have you had any of the following illnesses:  

(a)    Liver disease including jaundice
(b)    TB/ other serious infection
(c)    Heart attack
(d)    High blood pressure
(e)    Stroke
(f)    Epilepsy
(g)    Autoimmune condition e.g. Rheumatoid Arthritis
(h)    Kidney disease
(i)    Cancer
(j)    Psychiatric illness
(k)    Respiratory illness
(l)    Skin condition
(m)    Other  including allergies

2.    Have you had any surgery (apart from spinal surgery)? Please give details.

Section 5

The next questions are about your family€™s health. Has anyone of your blood relatives suffered from any of the following:?

(n)    Liver disease including jaundice
(o)    TB/ other serious infection
(p)    Heart attack
(q)    Stroke
(r)    Epilepsy
(s)    Autoimmune condition e.g. Rheumatoid Arthritis
(t)    Kidney disease
(u)    Cancer
(v)    Psychiatric illness
(w)   Respiratory illness
(x)    Inherited condition
(y)    Other
(z)    Do not know (adopted/fostered etc.)

Thank you for taking the time to fill out our Database

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Want to go to Questionnaire Three?