Trigeminal Neuralgia Genetic Information Sheet
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- Hillary Robertson
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1 Trigeminal Neuralgia Genetic Information Sheet **AFFECTED PARTICIPANT** *Please note Yale does not receive samples from HIV or Hepatitis positive participants* Please include as much information as possible attach records, summaries etc. Today s date Patient s Name (Last, First) Date of Birth (month/day/year) Gender Phone number: Address Race (e.g. Caucasian, Hispanic, African, Asian, Native American) Ethnicity (e.g. Irish, Italian, Puerto Rican, Scottish, Russian, Korean, etc.) Current weight: lbs 1
2 Current height: ft/in Clinical History of Trigeminal Neuralgia Age at diagnosis of trigeminal neuralgia Description of pain; is the pain: Unilateral (one-side of face)? If so, what side? Around eye (V1)? On cheek (V2)? On jaw (V3)? Other? Cross midline? Bilateral (both sides of face)? Lancinating/electrical/shock-like? Intermittent? If so, what is the duration of episodes? Pain-free intervals? Constant? Burning/aching? Triggered by anything? If so, what? Which type of trigeminal neuralgia describes you best: Type 1: >50% sharp and lancinating with pain-free intervals Type 2: >50% constant burning, aching, or throbbing symptoms 2
3 Neither, please describe: Have you received medication for this condition? Please specify the type(s) of medication, dose received and the duration of administration. Provide as much details as possible. Did your condition ever positively respond to the administration of medication (noticeably improve symptoms)? If so, which medications? Did your pain get better with carbamazepine? Did you eventually experience failure of pain control with medication? If so, please explain how long after you started the medication, and which medication was involved. 3
4 Have you ever had any surgical procedure for your Trigeminal Neuralgia such as microvascular decompression (MVD), thermal rhizotomy, balloon rhizotomy, or gamma knife surgery? If so, please specify the type of procedure and when it was performed. Also state if any procedures were performed more than once (i.e. 2 thermal rhizotomies, or 2 MVDs): Were any of the surgical procedures effective in significantly reducing pain? If so, please state which Current medications: Other medical problems/diagnoses/surgeries: 4
5 Did you have an MRI of your brain as part of your work-up for trigeminal neuralgia? If so, did show any abnormality? Please explain any abnormality: Clinical presentation (i.e. who made diagnosis and how was it discovered): 5
6 Additional history: Have you also been diagnosed with any of the following?: Hemifacial spasm? Glossopharyngeal neuralgia? Occipital neuralgia? Multiple sclerosis? Tolosa-Hunt syndrome Dental/sinus pain Temporomanidibular joint disease Post-herpetic neuralgia Cluster headaches? Migraines? Excessive tearing? Aneurysm? Brain tumor? Other brain abnormalities? Occupation: Exposure to recreational drugs? If so, please state which one History of any other chronic pain syndrome? If so, please state which one History of significant head or face trauma? If so, please explain 6
7 Family history: Is subject the result of a consanguineous union (mother and father related)? If Yes, please explain: Number of living siblings for subject Other family members affected with trigeminal neuralgia? If yes, please describe Other family members with an aneurysm or neurovascular abnormality? If yes, please describe Medical issues that run in the family? [give relation as well as condition (e.g. aunt had epilepsy)] Mother s side: Father s side: Children: Any relatives ever gone for genetic testing? (who, why, results of testing) If yes, please describe Other findings/comments that you would like for us to know: 7
8 Who are your doctors? Treating physician s name Institution Address Phone FAX Neurosurgeon / Neurologist s name Institution Address Phone FAX Thank you! Contact: Kristopher T. Kahle, M.D., Ph.D. Centers for Mendelian Genomics - Yale kristopher.kahle@yale.edu 8
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