David Schechter, M.D.

TMS Pain Diagram, Questionnaire, & Quadruple Visual Analogue Scale

Please complete the entire form to the best of your ability. Thank you!

FULL NAME * DATE *

PAIN DIAGRAM

How long have you had pain? *

Please indicate where you are experiencing pain or other symptoms, right now. Also indicate the type of pain in each area.

Anatomical Diagram Pain Diagram Upload

If you are unable to upload the diagram, answer the following questions. Indicate the type of pain in each area using the key below.

A=ACHE; P=PINS & NEEDLES; B=BURNING; S=STABBING; N=NUMBNESS; O=OTHER

ANTERIOR/FRONT OF BODY In the areas you listed above, what type of pain do you experience? POSTERIOR/BACK OF BODY In the areas you listed above, what type of pain do you experience?

TMS QUESTIONNAIRE

This questionnaire has been designed to help you evaluate the likelihood of your having TMS. It cannot replace a detailed medical history, examination, and review of x-rays and MRI scans. Only a medical doctor with expertise in this condition should make the diagnosis of TMS during an office consultation.

Please add your responses and total your points below:

1. Have you noticed a relationship between your pain and your emotional state/stress level just prior to the onset of pain? * 2. Would you describe yourself in general as: very hard on yourself, highly responsible for others, very thorough, orderly or perfectionistic? * 3. Have you suffered from other tension-related illnesses such as: hives, eczema, rashes brought on by tension; spastic colon, irritable bowel, gastritis, reflux/heartburn; tension or migraine headaches; unexplained prostate trouble or pelvic pain; TMJ, teeth grinding, plantar warts * 4. Have you been told regarding the cause of your pain that ?there?s nothing that can be done surgically,? ?there?s nothing wrong?, ?it?s a soft issue problem? or ?the cause is degenerative changes?? * 5. Do you spend a fair amount of time during the day thinking and worrying about your pain, researching an answer, obsessing about its cause? * 6. Have you tried several different treatments or approaches for your pain and received only temporary or limited relief from each of them? * 7. Do you find that massage helps your pain significantly or that you are quite sensitive to massage in several parts of your back or neck? * Total all points:

Additional Questions (don't score these):

8. Does the pain ever move to another location in your body or jump around? * 9. Have you noticed the pain improve when you have another tension-related illness? * 10. Has the pain significantly changed or gone away while on vacation, away from home, or while distracted? *

QUADRUPLE VISUAL ANALOGUE SCALE

Please check the number that best describes the question being asked.

Note: If you have more than one complaint, please check boxes for each individual complaint and indicate the score for each complaint. Please indicate your pain level right now, average pain, and pain at its best and worst.

1. What is your pain RIGHT NOW? * What areas of the body correspond to each number you checked above (#1)? 2. What is your TYPICAL or AVERAGE pain? * What areas of the body correspond to each number you checked above (#2)? 3. What is your pain level AT ITS BEST (How close to ?0? does your pain get at its best)? * What areas of the body correspond to each number you checked above (#3)? 4. What is your pain level AT ITS WORST (How close to ?10? does your pain get at its worst)? * What areas of the body correspond to each number you checked above (#4)? OTHER COMMENTS: