(*) denotes required information.
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| Do you have face pain (i.e., forehead, eye, cheek, nose, upper/lower jaw, teeth, lips, etc)? |
| Yes No |
| Do you remember the details of what you were doing and where you were the moment your facial pain started? |
| Yes No |
| Do you have pain just on one side of your face? |
| Yes No |
| Is your pain brief (seconds to minutes) but causing unpredictable, intense sensations? |
| Yes No |
| Do you have constant or more subdued facial pain (e.g., aching, burning, throbbing, stinging)? |
| Yes No |
| Do you have constant, more subdued facial pain for more than half of your waking hours? |
| Yes No |
| Do you have any constant facial numbness? |
| Yes No |
| Is your pain triggered by something touching your face (for example, eating, washing your face, shaving, brushing teeth, a gust of wind)? |
| Yes No |
| Since your pain began, have you experienced periods of weeks, months or years when you were pain-free? (Not including periods after any pain-relieving surgery or while you were on medications for your pain) |
| Yes No |
| Have you ever taken anticonvulsant medication for your pain, including Tegretol® (carbamazepine), Neurontin® (gabapentin), Lioresal® (baclofen), Treleptal® (oxcarbazepine), Topamax® (topiramate) or Zonegran® (zonisamide)? |
| Yes No |
| Did you ever experience any major reduction in facial pain (partial or complete) from taking any anticonvulsant medications? |
| Yes No |
| Have you ever had trigeminal nerve surgery for your pain (e.g., neurectomy, RF rhizotomy/gangliolysis, glycerol injection, balloon compression, rhizotomy, MVD, gamma knife)? |
| Yes No |
| Have you ever experienced any major reduction in facial pain (partial or complete) from previous trigeminal nerve surgery? |
| Yes No |
| Did your pain start only after facial surgery (oral surgery, ENT surgery, plastic surgery)? |
| Yes No |
| Did your pain start after facial zoster or a "shingles" rash? |
| Yes No |
| Do you have multiple sclerosis? |
| Yes No |
| Did your pain start after a facial injury? |
| Yes No |
| Place your index fingers on each of your outer cheeks, just in front of your ears and feel your jaw open and close. Does the area under your fingers on either side hurt? |
| Yes No |
| * First Name: |
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| * Last Name: |
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| * Email: |
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