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Today's Date: Oct 24, 2008
Authorization Number: 100002521
Language of the Questionnaire: English
Name of Questionnaire taken: Pain Questionnaire for Diagnose My Pain
Date the Questionnaire was
completed: 10/24/2008
Based on answered you gave on the questionnaire, you will find a list of possible
results, below.
These are organized by the testing company into groups to make calculations easier.
Please note
that a result in Group 1 does not mean a higher probability of occurrence than a result in
Group
4. These results should not be considered a diagnosis. However, any of the results in
bold print
should be discussed with your physician first.
The following is a report of those conditions and information that the patient
indicated on
the Pain Test:
The patient was born on 03/15/1967.
Patient reports that the pain is not the result of an accident. Patient reports having the
following
conditions: "Diabetes". The patient did not report having any of the following conditions:
"Thyroid
disease", "Lupus", "Multiple Sclerosis or M.S.", "Arthritis", "Cancer", "Heart disease, or
high blood
pressure, or stroke", "Infection", "Muscular Dystrophy". The injury that gave rise to the
claim
occurred on 01/01/1900. Patient reports not having had accidents or injuries before this
date.
Patient reports not having had accidents or injuries since this date.
Patient reports having no low back problems. Patient reports having had no surgery to
the low
back.
Patient reports having no problems in the left leg. Patient reports having had no surgery
or injury
to the left leg.
Patient reports having no problems with the right leg. Patient reports having had surgery
or injury
to the right leg.
Patient reports having a neck problem. Patient reports having had no surgery or injury
to the neck.
Patient reports that the neck problem, "comes and goes". Patient reports that the neck
problem is
a: "dull ache". Patient reports that the neck problem gets better if: "I use heat", "I use
massage".
Patient reports having no problems with the left arm. Patient reports having had no
surgery or
injury to the left arm.
Patient reports having no problems with the right arm. Patient reports having had no
surgery or
injury to the right arm.
-2-
Patient reports having a problem just in front of the ear (where the jaw hinges the skull).
Patient
reports that the jaw hinge problem, "comes and goes". Patient reports that the jaw hinge
problem
is a: "dull ache", "click in the jaw hinge". Patient reports that the jaw hinge problem is
made worse
by: "chewing", "opening or closing my jaw", "moving my jaw side to side". Patient
reports that the
jaw hinge problem is made better by: "the use of massage".
Patient reports having no problem with the chest or ribs. Patient reported having had no
injury to
the chest. Patient reported having had no surgery to the chest.
On the left side of the body, the patient reported the following:
Forehead, on the left side: "pain that comes and goes". Behind the left eye: "pain that
comes and
goes". Just in front of the left ear: "pain that comes and goes". In left temple: "pain that
comes and
goes". In left jaw: "pain that comes and goes". Over left eye, around eyebrow: "pain that
comes
and goes". Muscle behind left ear, coming forward and down left side of neck to
collarbone: "pain
that comes and goes".
A strip, on left side, from back of head up to the top: "pain that comes and goes". Back
left side of
head: "pain that comes and goes". Back of neck, on the left: "pain that comes and
goes". Across
top of left shoulder: "pain that comes and goes". Behind left ear, toward middle of neck:
"pain that
comes and goes".
Left calf: "spasm".
On the right side of the body, the paitient reported the following:
Forehead, on the right side: "pain that comes and goes". In right temple: "pain that
comes and
goes". In right jaw: "pain that comes and goes". Muscle behind right ear, coming forward
and
down right side of neck to collarbone: "pain that comes and goes".
A strip, on right side, from back of head up to the top: "pain that comes and goes". Back
of neck,
on the right: "pain that comes and goes". Across top of right shoulder: "pain that comes
and goes".
Behind right ear, toward middle of neck: "pain that comes and goes".
The patient also reported the following:
Left shoulder blade: "pain that comes and goes". Right shoulder blade: "pain that comes
and
goes".
The Patient reported no problems in the mid back. Patient reported having no injuries to
the mid
back. Patient reported having no surgeries on the mid back. Patient reported not having
a medical
problem other than injury or surgery in the mid back.
Please discuss with your doctor whether or not these terms, shown below, are
possible
causes for your pain:
Group 2 - Lumbar Herniated Disc L2-S1
-3-
‱ L5-S1 Radiculopathy
‱ L4-L5 Radiculopathy
Group 5 - Cervical Herniated Disc C4-C7
‱ C5-C6 Herniated or Disrupted Disc
‱ C4-C5 Herniated or Disrupted Disc
‱ C4-C5 Radiculopathy
Group 6 - Cervical Herniated Disc C2-C4
‱ Occipital Neuralgia
‱ C2-C3 Herniated or Disrupted Disc
‱ C-2 Root Compression
‱ C2-C3 Radiculopathy
Group 9 - Temporo-Mandibular Joint Syndrome
‱ Temporo-Manibular Joint Syndrome
‱ Muscle Tension Headache
Group 10 - Thoracic Outlet Syndrome
‱ Thoracic Outlet Syndrome
Group 15 - Herniated or Disrupted Thoracic Disc T1-T12
‱ T1-T4 Facet Syndrome
‱ T1-T4 Herniated or Disrupted Disc

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Sample test output Diagnose My Pain, for RSD, CRPS, fibromyalgia, whiplash, sprain, strain, disc, disk, TMJ,

  • 1. Today's Date: Oct 24, 2008 Authorization Number: 100002521 Language of the Questionnaire: English Name of Questionnaire taken: Pain Questionnaire for Diagnose My Pain Date the Questionnaire was completed: 10/24/2008 Based on answered you gave on the questionnaire, you will find a list of possible results, below. These are organized by the testing company into groups to make calculations easier. Please note that a result in Group 1 does not mean a higher probability of occurrence than a result in Group 4. These results should not be considered a diagnosis. However, any of the results in bold print should be discussed with your physician first. The following is a report of those conditions and information that the patient indicated on the Pain Test: The patient was born on 03/15/1967. Patient reports that the pain is not the result of an accident. Patient reports having the following conditions: "Diabetes". The patient did not report having any of the following conditions: "Thyroid disease", "Lupus", "Multiple Sclerosis or M.S.", "Arthritis", "Cancer", "Heart disease, or high blood pressure, or stroke", "Infection", "Muscular Dystrophy". The injury that gave rise to the claim occurred on 01/01/1900. Patient reports not having had accidents or injuries before this date. Patient reports not having had accidents or injuries since this date. Patient reports having no low back problems. Patient reports having had no surgery to the low back. Patient reports having no problems in the left leg. Patient reports having had no surgery or injury to the left leg. Patient reports having no problems with the right leg. Patient reports having had surgery or injury to the right leg. Patient reports having a neck problem. Patient reports having had no surgery or injury to the neck. Patient reports that the neck problem, "comes and goes". Patient reports that the neck problem is a: "dull ache". Patient reports that the neck problem gets better if: "I use heat", "I use massage".
  • 2. Patient reports having no problems with the left arm. Patient reports having had no surgery or injury to the left arm. Patient reports having no problems with the right arm. Patient reports having had no surgery or injury to the right arm. -2- Patient reports having a problem just in front of the ear (where the jaw hinges the skull). Patient reports that the jaw hinge problem, "comes and goes". Patient reports that the jaw hinge problem is a: "dull ache", "click in the jaw hinge". Patient reports that the jaw hinge problem is made worse by: "chewing", "opening or closing my jaw", "moving my jaw side to side". Patient reports that the jaw hinge problem is made better by: "the use of massage". Patient reports having no problem with the chest or ribs. Patient reported having had no injury to the chest. Patient reported having had no surgery to the chest. On the left side of the body, the patient reported the following: Forehead, on the left side: "pain that comes and goes". Behind the left eye: "pain that comes and goes". Just in front of the left ear: "pain that comes and goes". In left temple: "pain that comes and goes". In left jaw: "pain that comes and goes". Over left eye, around eyebrow: "pain that comes and goes". Muscle behind left ear, coming forward and down left side of neck to collarbone: "pain that comes and goes". A strip, on left side, from back of head up to the top: "pain that comes and goes". Back left side of head: "pain that comes and goes". Back of neck, on the left: "pain that comes and goes". Across top of left shoulder: "pain that comes and goes". Behind left ear, toward middle of neck: "pain that comes and goes". Left calf: "spasm". On the right side of the body, the paitient reported the following: Forehead, on the right side: "pain that comes and goes". In right temple: "pain that comes and goes". In right jaw: "pain that comes and goes". Muscle behind right ear, coming forward and down right side of neck to collarbone: "pain that comes and goes". A strip, on right side, from back of head up to the top: "pain that comes and goes". Back of neck, on the right: "pain that comes and goes". Across top of right shoulder: "pain that comes and goes".
  • 3. Behind right ear, toward middle of neck: "pain that comes and goes". The patient also reported the following: Left shoulder blade: "pain that comes and goes". Right shoulder blade: "pain that comes and goes". The Patient reported no problems in the mid back. Patient reported having no injuries to the mid back. Patient reported having no surgeries on the mid back. Patient reported not having a medical problem other than injury or surgery in the mid back. Please discuss with your doctor whether or not these terms, shown below, are possible causes for your pain: Group 2 - Lumbar Herniated Disc L2-S1 -3- ‱ L5-S1 Radiculopathy ‱ L4-L5 Radiculopathy Group 5 - Cervical Herniated Disc C4-C7 ‱ C5-C6 Herniated or Disrupted Disc ‱ C4-C5 Herniated or Disrupted Disc ‱ C4-C5 Radiculopathy Group 6 - Cervical Herniated Disc C2-C4 ‱ Occipital Neuralgia ‱ C2-C3 Herniated or Disrupted Disc ‱ C-2 Root Compression ‱ C2-C3 Radiculopathy Group 9 - Temporo-Mandibular Joint Syndrome ‱ Temporo-Manibular Joint Syndrome ‱ Muscle Tension Headache Group 10 - Thoracic Outlet Syndrome ‱ Thoracic Outlet Syndrome Group 15 - Herniated or Disrupted Thoracic Disc T1-T12 ‱ T1-T4 Facet Syndrome ‱ T1-T4 Herniated or Disrupted Disc