Timeline of Lifetime Trauma (TiLT) Inventory [Heidi]

**Timeline of Lifetime Trauma (TiLT) Inventory** Completion of this inventory may take 30 – 90 minutes. The detail requested by the questions in this inventory form is very important to fully understand your pain issues. Chronic pain is more common in individuals who have had injuries, surgery, or anatomical abnormalities that are not common in the general population. **Your Information** Your name as on your BC Services Card or your Driver’s Licence: [patient full legal name] (only include if explicitly mentioned in transcript or context, else omit section entirely) Your date of birth MM/DD/YYYY: [date of birth] (only include if explicitly mentioned in transcript or context, else omit section entirely) Your age: [patient age] (only include if explicitly mentioned in transcript or context, else omit section entirely) Your personal health number: [personal health number] (only include if explicitly mentioned in transcript or context, else omit section entirely) Your cell number: [mobile number] (only include if explicitly mentioned in transcript or context, else omit section entirely) Your home address: [home address] (only include if explicitly mentioned in transcript or context, else omit section entirely) Your email address: [email address] (only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 1 – Current Pain Problem** Issue 1 Location of pain: [location of pain for issue 1] (only include if explicitly mentioned in transcript or context, else omit section entirely) Worse on the right (R), left (L), or equal (E)?: [side dominance] (only include if explicitly mentioned in transcript or context, else omit section entirely) How long has this been a problem?: [duration] (only include if explicitly mentioned in transcript or context, else omit section entirely) Any aggravating posture or activity?: [aggravating factors] (only include if explicitly mentioned in transcript or context, else omit section entirely) Issue 2 Location of pain: [location of pain for issue 2] (only include if explicitly mentioned in transcript or context, else omit section entirely) Worse on the right (R), left (L), or equal (E)?: [side dominance] (only include if explicitly mentioned in transcript or context, else omit section entirely) How long has this been a problem?: [duration] (only include if explicitly mentioned in transcript or context, else omit section entirely) Any aggravating posture or activity?: [aggravating factors] (only include if explicitly mentioned in transcript or context, else omit section entirely) Issue 3 Location of pain: [location of pain for issue 3] (only include if explicitly mentioned in transcript or context, else omit section entirely) Worse on the right (R), left (L), or equal (E)?: [side dominance] (only include if explicitly mentioned in transcript or context, else omit section entirely) How long has this been a problem?: [duration] (only include if explicitly mentioned in transcript or context, else omit section entirely) Any aggravating posture or activity?: [aggravating factors] (only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 2 – Current Medications** Please list your current medications which are not analgesics, pain killers, or for treatment of your pain: [non-pain medications list] (only include if explicitly mentioned in transcript or context, else omit section entirely) Please list the medications which are used for treatment of your pain: [pain-related medications list] (only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 3 – Occupations / Work History** Age: [age at time of job 1] (only include if explicitly mentioned in transcript or context, else omit section entirely) Occupation / Job / Work Role: [job title 1] (only include if explicitly mentioned in transcript or context, else omit section entirely) Age: [age at time of job 2] (only include if explicitly mentioned in transcript or context, else omit section entirely) Occupation / Job / Work Role: [job title 2] (only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 4 – History of Competitive Sports and Recreational Activities** Age: [age during activity 1] (only include if explicitly mentioned in transcript or context, else omit section entirely) Sports / Recreational Activity: [activity 1] (only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 5 – Obstetrical History** Age: [age at obstetrical event 1] (only include if explicitly mentioned in transcript or context, else omit section entirely) Obstetrical Event: [description] (only include if explicitly mentioned in transcript or context, else omit section entirely) If you had an epidural during labour: [mark X if mentioned] (only include if explicitly mentioned in transcript or context, else omit section entirely) If you had an episiotomy: [mark X if mentioned] (only include if explicitly mentioned in transcript or context, else omit section entirely) If you had a diastasis recti repair: [mark X if mentioned] (only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 6 – Results of X-rays / MRIs / CTs / Ultrasounds** Age: [age at imaging 1] (only include if explicitly mentioned in transcript or context, else omit section entirely) Type: [e.g., X-ray, CT, MRI] (only include if explicitly mentioned in transcript or context, else omit section entirely) Imaging Results: [findings] (only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 7 – Surgical History** Age: [age at time of surgery 1] (only include if explicitly mentioned in transcript or context, else omit section entirely) Procedure Name / Location: [procedure name] (only include if explicitly mentioned in transcript or context, else omit section entirely) Reason for Procedure: [indication] (only include if explicitly mentioned in transcript or context, else omit section entirely) Complications: [if any] (only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 8 – Fractures** Age: [age at fracture 1] (only include if explicitly mentioned in transcript or context, else omit section entirely) Right/Left?: [side] (only include if explicitly mentioned in transcript or context, else omit section entirely) Bone(s) Involved: [fractured bones] (only include if explicitly mentioned in transcript or context, else omit section entirely) Treatment: [treatment type] (only include if explicitly mentioned in transcript or context, else omit section entirely) Complications: [complications] (only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 9 – If you ever had…** a fall on your tailbone Age: [age] (only include if explicitly mentioned in transcript or context, else omit section entirely) Duration: [days/weeks/months] (only include if explicitly mentioned in transcript or context, else omit section entirely) a chin laceration Age: [age] (only include if explicitly mentioned in transcript or context, else omit section entirely) Stitched or healed naturally: [S/N] (only include if explicitly mentioned in transcript or context, else omit section entirely) a lumbar puncture Age: [age] (only include if explicitly mentioned in transcript or context, else omit section entirely) Complications: [complication details] (only include if explicitly mentioned in transcript or context, else omit section entirely) chicken pox Age: [age] (only include if explicitly mentioned in transcript or context, else omit section entirely) Scars location(s): [body areas] (only include if explicitly mentioned in transcript or context, else omit section entirely) ankle sprains Age: [age] (only include if explicitly mentioned in transcript or context, else omit section entirely) Side(s): [R/L/B] (only include if explicitly mentioned in transcript or context, else omit section entirely) bad acne Age or range: [age or range] (only include if explicitly mentioned in transcript or context, else omit section entirely) Area: [F/C/B/U] (only include if explicitly mentioned in transcript or context, else omit section entirely) skin abscess or cellulitis Age: [age] (only include if explicitly mentioned in transcript or context, else omit section entirely) Location: [site] (only include if explicitly mentioned in transcript or context, else omit section entirely) road rash Age: [age] (only include if explicitly mentioned in transcript or context, else omit section entirely) Location: [site] (only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 10 – If you currently have…** immunization scars Locations: [RA/LA/RL/LL/RB/LB/S] (only include if explicitly mentioned in transcript or context, else omit section entirely) bunion Present: [R/L/B] (only include if explicitly mentioned in transcript or context, else omit section entirely) If painful, which side?: [R/L/B] (only include if explicitly mentioned in transcript or context, else omit section entirely) varicose vein Location: [site] (only include if explicitly mentioned in transcript or context, else omit section entirely) skin sensitivity Location: [site] (only include if explicitly mentioned in transcript or context, else omit section entirely) anxiety Symptoms: [physical symptoms] (only include if explicitly mentioned in transcript or context, else omit section entirely) depression/mood Lower face skin changes: [description] (only include if explicitly mentioned in transcript or context, else omit section entirely) headaches/migraines Area: [location] (only include if explicitly mentioned in transcript or context, else omit section entirely) Frequency: [number per month] (only include if explicitly mentioned in transcript or context, else omit section entirely) restricted movement Description: [movement] (only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 11 – Free Recall** Other trauma/surgical/medical history: [description] (only include if explicitly mentioned in transcript or context, else omit section entirely) Your Trauma / Medical History (use the letters R for right, L for left, B for both or bilateral) Age: [include age] Trauma or Medical Problem / Location: [problem or site at age stated] (only include if explicitly mentioned in transcript or context, else omit section entirely) Cause: [cause at age stated] (only include if explicitly mentioned in transcript or context, else omit section entirely) Treatment: [treatment at age stated] (only include if explicitly mentioned in transcript or context, else omit section entirely) Complication: [complication at age stated] (only include if explicitly mentioned in transcript or context, else omit section entirely) (Repeat the above structure for each age or age range mentioned in the transcript or context. Do not create entries for ages not referenced.only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 12 – Memory Triggers** Types of Soft Tissue Trauma Trauma Type: Transport Related Injuries / Motor Vehicle Accidents Subtype: with another car Age: [age at time of trauma with another car] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of car accident] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: with a truck Age: [age at time of trauma with truck] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of truck accident] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: on a motorcycle Age: [age at time of motorcycle accident] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of motorcycle fall or injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: on a bicycle Age: [age at time of bicycle accident] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of bicycle accident] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: on public transit Age: [age at time of public transit trauma] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of transit incident] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: as a pedestrian Age: [age at time of pedestrian injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of injury while walking] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Surgery Subtype: major Age: [age at time of major surgery] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of major surgical procedure] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: minor Age: [age at time of minor surgery] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of minor surgical procedure] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: childhood Age: [age at childhood surgery] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of childhood surgery] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: skin cancer Age: [age at time of skin cancer surgery] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [location and type of skin cancer excision] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: cosmetic Age: [age at time of cosmetic surgery] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of cosmetic procedure] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: surgical drain scars Age: [age at time of surgical drain] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [location and purpose of surgical drain] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: bone or skin grafts Age: [age at time of graft] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [location and reason for graft] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: tissue biopsies Age: [age at time of biopsy] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [location and type of biopsy] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Fractures Subtype: treated by a cast Age: [age at time of cast-treated fracture] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [fracture location and cast detail] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: surgically treated Age: [age at time of surgical fracture treatment] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of surgical fixation] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Repeated Sprains Age: [age at time of repeated sprains] (only include if explicitly mentioned in transcript or context, else omit section entirely) Joint involved: [location of repeated sprain(s)] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Falls Subtype: from height Age: [age at time of fall from height] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of fall and injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: onto tailbone Age: [age at time of tailbone fall] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [tailbone trauma details] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Sports Injuries Age: [age at time of sports injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [type of sports injury and impact] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Recreation Injuries Age: [age at time of recreational injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [recreational activity and injury details] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Childhood Injuries Subtype: bleeding events Age: [age at time of bleeding injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [location and treatment of bleeding injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: crushing events Age: [age at time of crushing trauma] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of crushing injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Assaults Subtype: no skin penetration Age: [age at time of non-penetrative assault] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of incident, include affected side(s)] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: skin penetration Age: [age at time of penetrative assault] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of injury and location on body] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Concussions Subtype: something struck you Age: [age at time of impact injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [event description, including what struck and body part affected] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: you struck something Age: [age at time you struck object] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of event and injury site] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Lacerations Subtype: glass Age: [age at time of glass injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description including location and severity] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: metal Age: [age at time of metal-related injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of metal laceration, include side of body] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: to face Age: [age at time of facial laceration] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of facial trauma] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: on chin Age: [age at time of chin laceration] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [details of fall and chin injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: other Age: [age at time of other laceration] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of other laceration, location and treatment] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Penetrating Wounds Subtype: weapon – note type Age: [age at time of weapon injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of wound and affected side/body part] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: metal Age: [age at time of metal penetration injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [location and detail of puncture injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: wood / stick / sliver Age: [age at time of sliver injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [location and nature of wood/stick injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Skin Lesions Subtype: cystic acne Age: [age at time of cystic acne] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [location of acne lesions] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: shingles Age: [age at time of shingles] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [affected region (e.g., left chest wall)] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: chicken pox scar Age: [age when scar was noticed] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of scar locations] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Burns Subtype: heat/thermal Age: [age at time of thermal burn] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description including affected body region and cause] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: chemical Age: [age at time of chemical burn] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [substance involved and injury site] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: electrical Age: [age at time of electrical injury] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [scenario and body part affected] (only include if explicitly mentioned in transcript or context, else omit section entirely) Subtype: notable sunburn(s) Age: [age during notable sunburn(s)] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [description of area repeatedly burned] (only include if explicitly mentioned in transcript or context, else omit section entirely) Trauma Type: Animal Bites Subtype: note animal type Age: [age at time of animal bite] (only include if explicitly mentioned in transcript or context, else omit section entirely) Event: [animal involved and bite location] (only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 13 – Scars** [Include any instructional commentary or clinician-prompted discussion on whether the patient has other scars not already recorded, and describe the relevance of soft tissue injuries, including how old or invisible scars can impact biomechanics, growth, or pain. May include encouragement to inspect skin or involve others in observation.] (only include if explicitly mentioned in transcript or context, else omit section entirely) [description of any other scar(s) not already recorded and the event that caused them] (only include if explicitly mentioned in transcript or context, else omit section entirely) **Step 14 – Most Significant Lifetime Event** Your first significant physical trauma in childhood: [description of first major childhood trauma] (only include if explicitly mentioned in transcript or context, else omit section entirely) The most significant physical trauma in your lifetime: [description of most significant trauma overall] (only include if explicitly mentioned in transcript or context, else omit section entirely) The injury which resulted in the most amount of bleeding: [description of injury with greatest bleeding] (only include if explicitly mentioned in transcript or context, else omit section entirely) The physical trauma which caused the greatest emotional trauma in your lifetime: [description of trauma with greatest emotional impact] (only include if explicitly mentioned in transcript or context, else omit section entirely) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)