1. When
were you diagnosed with Arachnoiditis?
(delete those which do not apply) 1 to 5 years,
5 to 10 years, or over 10 years ago.
Which
spinal area is involved? lumbar/thoracic/cervical
Do you have cranial involvement?
Yes/No
Do
you have any other existing spinal condition e.g.
stenosis (narrowing), herniated discs, degenerative
problems..if so, where and what?
2. How
long did you have symptoms prior to diagnosis?
1-5years, 5-10years, over 10 yrs
3. What
was your initial back problem?
4. Do you have spina bifida occulta? Yes/No
5.
Have you had surgery? If so, lease specify
when and what procedure(s)
6.
Have you had spinal (epidural) anaesthetic for
any surgery or in childbirth. If so, please give
details .
7. Have
you had 1 or more myelograms? If so, how many
and which contrast medium(s) was used?
8. Have
you had 1 or more epidural steroid injections?
9. Do
you have any other current diagnoses, e.g. diabetes,
fibromyalgia, MS?
10 Have you had any serious illnesses in the
past, especiallyliver/kidney problems?
11.
What medication are you currently using?
If on morphine or other opiate,please state how
long you have been using it.
12.
Please state if you have used any of the following:
anti-inflammatory drugs such as Brufen, Naproxen
(for how long?) anticonvulsant drugs such Tegretol
opiate drugs
13. Have you ever had a serious viral infection
such as glandular fever, hepatitis: Yes?No?
If Yes, please specify, and when.
14.
Have you ever had meningitis? Yes/No If,
Yes, how long ago?
15.
Which parts of the body cause you pain?
Please delete those which do not apply:
head
face
neck
shoulders
chest
back(upper thoracic)
front
abdomen
lumbar spine/lower thoracic
pelvis/groin
hips
legs
feet
joints (if so, which?)
16.
How would you describe your pain(s)? Please
delete those which do not apply and indicate where
these pains are physically:
burning
gripping
stabbing
electric shock
other(please specify)
17.
Do you experience other unpleasant sensations,
not including tingling? Please try to describe
them.
18. Please delete those which do not apply
to you from the following list of symptoms/conditions/diseases:
Stiffness :
Muscle cramps/twitches/spasms
Weakness
Balance difficulties
Numbness/tingling
Bladder/bowel/sexual dysfunction
Difficulty in thinking clearly/decision making/memory
Depression/anxiety
Sleep disturbance
Increased/decreased sweating
Heat intolerance
Intermittent low grade fevers
Flu-like feeling and malaise
Raised ESR /white cell count
Enlarged lymph nodes
Joint pains
Skin rashes
Frequent infections
Sinusitis
Slow healing/tendency to scar easily
Limbs/generalised swelling
Trouble swallowing
Angina type chest pain (but no heart disease found)
Weight gain
Reduced mobility (i.e. house/chair/bed bound?)
Allergies (new, e.g. multiple drug allergies)
Dizziness/vertigo
Dry eyes/mouth
Bruising
Fatigue
Dental problems (tooth/gum)
Low potassium
Abnormal blood tests
Abnormal kidney function
Abnormal liver enzymes
Osteoporosis
Shortness of breath
Lung problems
Diagnosis of : Sjogren’s disease
Lupus
Raynaud’s disease
Other autoimmune disease
Diagnosis of MS
Diagnosis of fibromyalgia/chronic fatigue syndrome/M.E.
Gastrointestinal problems e.g. irritable bowel
syndrome/colitis/indigestion
Visual problems
Female respondents only: menstrual irregularities,
if pre-menopausal, otherwise earlymenopause/painful
periods.
Thank you for responding. The data gathered
from the survey will be used to help other sufferers
