FORMULAIRE D’INSCRIPTIONS ANGLAIS

AQDC MEMBERSHIP FORM

Personal information

Name *

Prénom

Nom

E-mail *

Adresse *

Adresse ligne 1

Ville

État / Province / Région

Code postal

Phone number *

Demographics

What is your sex? *

Female
Male
I prefer not to tell
I prefer to define myself

I describe myself as *

What is your age group? *

Less than 17 years
18 - 20 years
21 - 29 years
30 - 39 years
40 - 49 years
50 - 59 years
60 - 69 years
70 - 79 years
80 - 89 years
90 years and older

What is your current education level? *

Elementary
Highschool
Technical school or CEGEP
University degree (Bachelor, undergraduate studies)
University degree (Master, graduate studies)
University degree (PhD, graduate studies)
None

What is your marital status? *

Single
Married or common-law union
Separated or divorced
Widowed

Which region do you live? *

Specify your region *

What is the main language spoken at home? *

French
English
Other

What is your current employee status? *

Currently working full-time
Currently working part-time
Looking for work, unemployed
Sick leave or maternity leave
Temporary disability due to my pain
Permanent disability due to my pain
Disability for other reasons than my pain
Student
Temporary lay off
Retired
At home
Other

What is your annual family income (CAD) before deductions? *

$0 to $9,999
$10,000 to $19,999
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 to $89,999
$90,000 to $99,999
$100,000 and over
I prefer not to tell

FAMILY INCOME: We remind you that all the information collected in this survey will remain strictly confidential and will be processed on anonymous basis.

Are you? *

A caregiver
A person living with chronic pain
Other

What type of pain do you have? *

Chronic pelvic pain in men
Dysmenorrhea (menstrual cramps)
Interstitial cystitis (pain in the bladder)
Vulvodynia
Back, neck and joint pain
Facet arthropathy
Osteoarthritis
Degenerative disc disease
Sacroiliac pain
Sciatica (sciatic neuralgia)
Cervical (neck) spain-related problems
Spinal stenosis
Piriformis syndrome
Headaches
Cluster headaches
Cervicogenic headache
Tension headache
Migraine
Temporomandibular joint dysfunction
Neuropathy
Neuropathic pain
Painful diabetic neuropathy
Facial neuralgia and atypical facial pain
Complex regional pain syndrome
Shingles and post-herpetic neuralgia
Generalized pain syndrome
Fibromyalgia
Myofascial pain
Central sensitisation/Opioid-induced hyperalgesia
Other types of chronic pain
Chronic fatigue syndrome
Endometriosis
Inflammatory bowel disease
Irritable bowel syndrome
Multiple sclerosis
Rheumatoid arthritis
Cerebrovascular accident
Systemic lupus erythematosus
Traumatic brain injury
Other chronic illness/comments

You may check more than one box.

Other chronic illness/comments *

How long have you been experiencing pain? *

Please indicate the circumstances surrounding the apparition of your pain. If you experience pain in more than one place, answer this question while considering the region that the pain interferes the most with your daily life. *

Work accident
Motorized vehicle accident
Home accident
Sports accident
Public space accident
During or following cancer
During or following a disease (other than cancer)
After surgery
Repetitive movement/trauma
Stressful event
No specific event
Other reason or event

Health services

Do you have a general practitioner? *

Yes
No

What type of clinic does your family doctor belong to? *

A doctors-only clinic
A family medicine group (FMG)
A CLSC
He has a private office
Other. Specify in comments
I don't know

Comments *

Are you currently seeking care or have you visited in the past any of the following healthcare professionals? *

Acupuncturist
Anesthesiologist
Chiropractor
Orthopedic surgeon
Plastic surgeon
Occupational therapist
Geriatrician
Homeopath
Nurse
Kinesiologist
Massage therapist
General practitioner
Naturopath
Nutritionist
Orthotist
Osteopath
Pharmacist
Physiatrist
Physiotherapist
Psychologist
Interventional radiologist
Rheumatologist
Social worker
Emergency physician
Other
None

Do you have access to a multidisciplinary pain management clinic? *

Yes, I currently receive treatment in this type of clinic.
No, but I am on a waiting list.
No, but I have been treated in this type of clinic in the past.
No, I have never been referred to this type of clinic.

How long have you been on a waiting list? *

Which chronic pain clinic do you have access to? *

Alan Edwards Pain Management Unit. McGill University Health Centre
Centre de gestion de la douleur de l'Hôpital Maisonneuve-Rosemont
Lethbridge-Layton-Mackay Rehabilitation Centre
Centre de traitement de la douleur du CHU de Québec-RUIS Université Laval
Centre expertise en gestion de douleur chronique
Centre hospitalier de Gaspé (Pavillon Hôtel-Dieu)
Centre hospitalier de Verdun
Centre hospitalier Rouyn-Noranda
Centre hospitalier régional de Rimouski
Centre hospitalier universitaire de Montréal, Hôtel-Dieu de Montréal
Centre hospitalier universitaire de Québec
Centre hospitalier universitaire de Sherbrooke
Centre interdisciplinaire en gestion de la douleur du CSSS Alphonse-Desjardins, CHAU de Lévis
Centre Montérégien de réadaptation
Centre régional en gestion de la douleur chronique de la Côte-Nord Sept-Îles
McGill University Health Centre, Montreal General Hospital
McGill University Health Centre, Montreal Children’s Hospital
Chronic Pain Clinic, Jewish General Hospital
Chronic Pain Service, Montreal Children's Hospital
CHRTR - Pavillon Sainte-Marie
CISSS Montérégie-Ouest programme spécialisé douleurs chroniques
Cité de la santé de Laval
Clinique antidouleur CSSSI
Clinique d'adaptation à la douleur chronique, Centre de réadaptation Lucie-Bruneau
Clinique d'algologie de la cité de la santé de Laval
Clinique de douleur chronique, Montreal Neurological Institute-Hospital
Clinique de douleur CSSS de la Mitis
Clinique de douleur Rimouski
Clinique de gestion de la douleur chronique, Institut universitaire de gériatrie de Montréal
Clinique de la Douleur Chronique CIUSSS MCQ
Clinique de la douleur de l'Hôpital du Haut-Richelieu
Clinique de la douleur de St-Jérôme
Clinique de la douleur du CHUM
Clinique de la douleur du CHUSJ
Clinique de la douleur d'Amos
Clinique de la douleur Hôtel-Dieu de Gaspé
Clinique du soulagement de la douleur, Hôpital Verdun
Clinique Interdisiplinaire de gestion de la douleur chronique du Saguenay Lac-St Jean
Clinique régionale spécialisée de douleur chronique CISSSSAT à Rouyn-Noranda
CSSS Domaine-du-Roy
CSSS Maria-Chapdelaine
Hôpital Charles LeMoyne
Hôpital général juif-Sir Mortimer B. Davis
Hôpital Hôtel-Dieu de Saint-Jérôme
Hôpital Maisonneuve-Rosemont
Hôpital Pierre Boucher - gestion de la douleur
Hôpital Sainte-Justine
Montreal Heart Institute
Institut de réadaptation en déficience physique
Montreal Neurologic Hospital Neuromodulation Pain Clinic
Programme d'adaptation à la douleur chronique
Programme d'expertise de réadaptation en douleur chronique
Service de Gestion de la Douleur Chronique de l'hôpital Pierre-Boucher
None

Do you use prescription medication to manage your pain? *

Yes
No

What prescription medications do you take to manage your pain? *

(Include here only medications that have been prescribed to you, exclude natural products and other substances). For the sake of accuracy, we suggest that you pick up the bottles of pain medication you are taking and write the names of the medications on the bottles in the space below.