Tarlov Cyst Disease Foundation Patient Survey
I. General Information
address optional ;* state/country required
D. Current Age
E. Age at onset of symptoms
A. Date of onset of symptoms
B. Significant occurrences at onset of symptoms. Check all that apply.
D. If you answered "yes" to B., did you receive surgical treatment?
(If yes, briefly describe)
E. Non-surgical treatments you received. Check all that apply.
G. Who did you FIRST see for diagnosis and treatment?
H. Describe your initial Symptoms (Briefly)
I. Diagnostic Tests you had initially: Check all that apply
J. Referrals to other Health Care Practitioners?
K. If yes, Check all that apply.
L. Did a Neuroradiologist read your MRI/CT/Myelogram?
(If not, who read it?)
M. Who initially diagnosed your Tarlov cyst?
N. What is/are the location of your cyst(s)?
Number of cysts
P. Did any doctors tell you that:
What treatment options were described for you by your physician or referred physician?
Check all that apply
IV.Other Diagnosis/Medical Conditions
Type inside the box below any other medical diagnosis that you have in addition
to TCs, such as congenital defects, connective tissue disorders, etc.
V.Other findings on your MRI/CT scan
Type inside the box below any treatments you have had for your Tarlov cysts and
a brief comment after each as to improvement, no improvement, worse
Type inside the box any medications you have taken for Tarlov cysts and if they
helped your symptoms or not.
A. Are you currently employed?
C. Are you unable to work due to Tarlov cyst symptoms?
D. Have you applied for Social Security Disability?
Do you still: (Use the following codes for items below- S (same as usual)
O (Occasionally) R (Rarely) N (Never)
F. Do you have problems with the following? (use same codes as in E. above)
H. What is your most uncomfortable position?
IX.Personal Impact of Living with Tarlov cysts
A.What can you no longer do because of your Tarlov cyst symptoms?
What has changed in your life since the TC diagnosis, such as loss of job,
social life, etc.
X. List 5 things you would like your family and friends to know about your Tarlov
XI. List 5 things you would like your physician to know about you and your Tarlov