Complex Regional Pain Syndrome Detailed Questionnaire

Please read this carefully before completing this form

Please answer all questions as accurately as possible. This questionnaire is designed to obtain a comprehensive picture of your medical history, current medications, and ongoing commitments to assess if you might be suitable for one of our studies. Please note that as you complete this form, we automatically save the data on our secure internal database (Zoho). By filling out this form, you give your consent for the data you provide to be held on the database. If you are not suitable for a current trial on review of the data you have provided, you have given consent for us to hold your personal data on our database so that we can get in touch should a trial arrive that suits your situation. If you are experiencing any issues completing this questionnaire, please email us at [email protected] or you can call us at 0203 865 1142. Please note, under UK Data Protection legislation, SPCR requires the consent of potential and current trial participants to hold their personal data on our secure internal database (Zoho) indefinitely. Our database is accessible by SPCR staff only, and the data is used solely for the purpose of informing those participants about relevant clinical studies. Individuals may revise or remove their data at any time by contacting SPCR. Our Participant Privacy Policy can be found on the website.

Name*

First Last

Phone*

Email*

Address*

Address Line 1 Address Line 2 City County Post Code Country

Are you between the ages of 18 and 75 years old?*

Yes
No

Date of Birth*

Are you willing and able to travel to London for clinic visits?*

Yes
No

Have you been diagnosed with CRPS?*

Yes
No
I suspect I might have it

Date of CRPS diagnosis, or date of symptoms of suspected CRPS starting:

If you cannot remember the exact date, please provide the year in which you were diagnosed, by typing "00/00" for the day and month.

Have you experienced any of the following symptoms? (may check more than one)*

Heightened sensitivity to pain and/or feels pain from nonpainful stimuli
Temperature asymmetry and/or skin color changes or asymmetry
Swelling and/or sweating changes or asymmetry
Decreased range of motion and/or motor dysfunction and/or changes in hair, skin, or nails
None of the above
I am not sure
Other

If Other, please give further details:

CRPS Details

Step 1 of 2

Please read this carefully before completing this form

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