Skip to main content

Search for:

Contact us News

Understanding CRPS
Advancing Research
Get Involved
- Tell Your Story
- Spread Awareness
About Us
- Our Story
- Our Team
Donate
Resource Library

Patient Survey

Participate in research

We developed a patient survey so you can participate in the research process. Help us learn about different originating traumas and triggers, effective treatments and therapies, as well as sharing competent, compassionate healthcare providers and therapists.

CRPS Patient Survey

Name(Required)

First Name First Letter of Last Name

Gender(Required)

Age(Required)

State(Required)

City(Required)

How long have you suffered from CRPS?(Required)

Which limb(s) or other body parts are affected(Required)

Has the CRPS spread since the original diagnosis?(Required)

Describe the initial injury that triggered the condition(Required)

How long was it after the injury before you were correctly diagnosed?(Required)

How many practitioners did you see before the correct diagnosis?(Required)

What type of practitioner made the diagnosis(Required)

Orthopedist

Neurologist

Pain Management Specialist

Other

If other, please specify

Were you diagnosed with CRPS(Required)

Type 1

Type 2

Unknown origin

Prior to the inciting injury, did you have any other neuropathic conditions such as:(Required)

Shingles

Fibermyalgia

Migraine headaches

Other

If other, please specify

Prior to the inciting injury, did you have any other conditions that may be relevant to the onset of CRPS.(Required)

Describe your current treatment regimen including any drugs, physical therapy, neurostimulation treatments, counseling, etc.(Required)

Have you ever been treated with ketamine or low-dose naltrexone?(Required)

Which treatments do you feel worked best for you?(Required)

Which treatments were the least effective or made the condition worse?(Required)

Have you had any extended remissions after any of the therapies and if yes, how long did it last?(Required)

Describe any external stimuli or conditions that trigger more pain(Required)

Are there any stimuli or conditions that make you feel better?(Required)

Music

Watching a movie

Immersion in warm water

Wrapping the affected area

Exercise

Other

If other, please specify

Are you satisfied with your current practitioner(s)?(Required)

Yes

No

Do you feel like your current practitioner(s) are taking a holistic approach to treat the CRPS?(Required)

Yes

No

If you like your practitioners would you recommend them to other CRPS patients? if yes, please provide their name, city, and state to help us generate a list of recommended compassionate, qualified therapists(Required)

Do you feel that most of your family and/or primary caregivers understand your condition and what could they do to improve your relationship with them?(Required)

Do you have any additional comments that could be relevant to our research project?(Required)

Although your story is important to us, we understand if you do not want to take part in our online survey. You can also share it with us at the following PO Box: TJWM Foundation P.O. Box 28878 Santa Fe, NM. 87592

CAPTCHA

ALWAYS STAY UP-TO-DATE

Join Our Newsletter

Name(Required)

First

Email(Required)

CAPTCHA

Follow us

TJWM Foundation P.O. Box 28878 Santa Fe, NM. 87592

info@tjwhalenfoundation.org

Let us know what you think about our website and complete our Website Survey

Contact Us Resource Library

Copyright 2023 | EIN: 12-3456789 | Nonprofit Website Design by Elevation

Terms of use Privacy Policy