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 MALE QUESTIONNAIRE - PAGE 3(a) 

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This section deals with unusual skin sensations, or lack of sensation.
310.  Do you sometimes have a burning or tingling sensation on your face?
Don't know
Never
Mild / occasionally
Moderate / frequently
Severe / constantly
311.  Do you sometimes experience pain on one or both sides of your face?
Don't know
No
Yes, tends to be a constant pain
Moderate shooting type pain
Sudden, severe, or lancing pain
312.  Have you experienced a gradual loss of sensation (numbness) in an arm or leg within the past year?
No / don't know
Yes, but it was an episode more than a year ago
Yes, but it is improving now
Slight numbness, stable or getting worse
Significant numbness, stable or getting worse
313.  Do you have numbness, tingling or burning in the extremities (toes, fingers)?
No / don't know
Yes, some
Yes, significant
314.  Have you experienced a loss or reduction of your sense of touch?
Don't know
In the past only, now resolved
Yes, it started more than 1 year ago
Yes, it started less than 1 year ago
Yes, it started less than 1 month ago
315.  Do you suffer from tenderness to touch that is made worse by (for example) bedsheets, socks or tight-fitting shoes? This is a condition known as hyperalgesia.
Don't know
No
Yes, somewhat
Yes, severe
316.  Do you have difficulty in telling (feeling) the difference between hot and cold?
Don't know
No
Somewhat
Definitely
317.  Do you have any other skin sensations that can only be described as "strange"?
Don't know
No
Occasionally - a few times each year
Regularly - a few times per month
Frequently or (almost) always

Add any additional information here for the questions above:

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GLOSSARY

Hyperalgesia
A condition of altered perception such that stimuli which would normally induce a trivial discomfort cause significant pain.





























 
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