Surveys | Tarlov Cyst Disease Foundation

I. General Information

Name / Pseudonym*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Street address optional; state/country required

Gender

Male
Female

Race/Ethnicity

Current Age

Age at Onset of Symptoms

II. History

Year of Onset of Symptoms

Significant occurrences at onset of symptoms. Check all that apply.

Fall
Rear end collision
Other motor vehicle accident (MVA)
Lifting heavy object
Long car trip
Plane trip
Other
No particular significant incident

Please describe incident.

Prior to Tarlov cyst diagnosis, had you experienced back pain or back injury with any other diagnosis?

Yes
No

Did you receive surgical treatment?

Yes
No

Please briefly describe.

Non-surgical treatments you received. Check all that apply.

Massage Therapy
Physical Therapy
Acupuncture
Ice application
Heat application
Bed rest
Muscle relaxants
Other

Please describe.

Date of first medical visit for Tarlov Cyst symptoms:

Who did you FIRST see for diagnosis and treatment?

Family Practice / GP
Orthopedist
Neurologist
Neurosurgeon
Other

Briefly describe your initial symptoms.

Diagnostic Tests you had initially. Check all that apply.

X-Ray
EMG
MRI
Myelogram
CT
Other

Referrals to other Health Care Practitioners?

Yes
No

Check all that apply.

Neurologist
Neurosurgeon
Orthopedic Specialist
Psychiatrist
Physical Therapist
Acupuncturist
Interventional Neuroradiologist
Other

Please describe.

Did a Neuroradiologist read your MRI/CT/Myelogram?

Yes
No

Who read it?

Who initially diagnosed your Tarlov cyst?

What is/are the location of your cyst(s)?

Size(s)

Number of cysts

Were there other names used for your cyst other than Tarlov?

Did any doctors tell you that Tarlov cysts were the cause of your symptoms?

Yes
No

Did any doctors tell you that Tarlov cysts were never symptomatic?

Yes
No

Did any doctors tell you that they did not know what a Tarlov cyst is?

Yes
No

What treatment options were described for you by your physician or referred physician?

III. Symptoms

Check all that apply.

Please describe.

Other Diagnosis / Medical Conditions

Any other medical diagnosis that you have in addition to TCs, such as congenital defects, connective tissue disorders, etc.

Other findings on your MRI/CT scan

Ruptured/Herniated Discs - Location(s)

Bulging Discs - Location(s)

Arachnoiditis - Type

Osteoarthritis - Location

Scoliosis

Kyphosis

Lordosis

Spondylolisthesis

Other

Treatment Outcomes

Any treatments you have had for your Tarlov cysts and a brief comment after each as to improvement, no improvement, worse.

Medications

Any medications you have taken for Tarlov cysts and if they helped your symptoms or not.

Activity Level

Are you currently employed?

Yes
No

What is your current job or, if not currently employed, what was your previous job?

Are you unable to work due to Tarlov cyst symptoms?

Yes
No

Have you applied for Social Security Disability?

Yes
No

Do you still: (Use the following codes for items below)

S (same as usual)
O (Occasionally)
R (Rarely)
N (Never)

Drive

Travel

Vacuum

Cook

Garden

Mow the lawn

Exercise - if so, what type?

Go to the theatre or movies

Go out to eat

Do you have problems with: (Use the following codes for items below)

S (same as usual)
O (Occasionally)
R (Rarely)
N (Never)

Sitting

Standing

Lying flat on your back

Lying on the side of your cyst

Walking

Bending at the waist

What is your preferred position of least discomfort?

What is your most uncomfortable position?

Personal Impact of Living with Tarlov Cysts

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.?

List 5 things you would like your family and friends to know about your Tarlov cyst Diagnosis.

List 5 things you would like your physician to know about you and your Tarlov cyst(s).

Comments

This field is for validation purposes and should be left unchanged.

Tarlov Cyst Disease Foundation

Surveys & Research

I. General Information

II. History

III. Symptoms

Activity Level

Do you still: (Use the following codes for items below)

Do you have problems with: (Use the following codes for items below)

Personal Impact of Living with Tarlov Cysts

Tarlov Cyst Disease Foundation