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: Jane Doe Your date of birth MM/DD/YYYY: 05/12/1978 Your age: 46 Your personal health number: 123-456-789 Your cell number: 555-123-4567 Your home address: 123 Main St, Anytown, BC Your email address: jane.doe@email.com **Step 1 – Current Pain Problem** Issue 1 Location of pain: Lower back Worse on the right (R), left (L), or equal (E)?: E How long has this been a problem?: 6 months Any aggravating posture or activity?: Prolonged sitting Issue 2 Location of pain: Right knee Worse on the right (R), left (L), or equal (E)?: R How long has this been a problem?: 2 years Any aggravating posture or activity?: Squatting Issue 3 Location of pain: Left shoulder Worse on the right (R), left (L), or equal (E)?: L How long has this been a problem?: 1 month Any aggravating posture or activity?: Overhead reaching **Step 2 – Current Medications** Please list your current medications which are not analgesics, pain killers, or for treatment of your pain: Lisinopril 10mg daily, Vitamin D 1000 IU daily Please list the medications which are used for treatment of your pain: Acetaminophen 500mg as needed, Ibuprofen 200mg as needed **Step 3 – Occupations / Work History** Age: 22 Occupation / Job / Work Role: Waitress Age: 30 Occupation / Job / Work Role: Office Administrator **Step 4 – History of Competitive Sports and Recreational Activities** Age: 15 Sports / Recreational Activity: Soccer **Step 5 – Obstetrical History** Age: 28 Obstetrical Event: Vaginal delivery If you had an epidural during labour: X If you had an episiotomy: If you had a diastasis recti repair: **Step 6 – Results of X-rays / MRIs / CTs / Ultrasounds** Age: 44 Type: MRI Imaging Results: Mild degenerative changes in lumbar spine **Step 7 – Surgical History** Age: 35 Procedure Name / Location: Appendectomy Reason for Procedure: Appendicitis Complications: **Step 8 – Fractures** Age: 16 Right/Left?: L Bone(s) Involved: Tibia Treatment: Cast Complications: **Step 9 – If you ever had…** a fall on your tailbone Age: 10 Duration: 2 weeks a chin laceration Age: 8 Stitched or healed naturally: S a lumbar puncture Age: Complications: chicken pox Age: 6 Scars location(s): Trunk ankle sprains Age: 17 Side(s): L bad acne Age or range: 14-18 Area: F skin abscess or cellulitis Age: Location: road rash Age: Location: **Step 10 – If you currently have…** immunization scars Locations: RA bunion Present: B If painful, which side?: L varicose vein Location: Left leg skin sensitivity Location: anxiety Symptoms: depression/mood Lower face skin changes: headaches/migraines Area: Frequency: restricted movement Description: **Step 11 – Free Recall** Other trauma/surgical/medical history: None Your Trauma / Medical History (use the letters R for right, L for left, B for both or bilateral) Age: 16 Trauma or Medical Problem / Location: Left Tibia Fracture Cause: Soccer injury Treatment: Cast Complication: Age: 35 Trauma or Medical Problem / Location: Appendectomy Cause: Appendicitis Treatment: Surgical removal Complication: **Step 12 – Memory Triggers** Types of Soft Tissue Trauma Trauma Type: Transport Related Injuries / Motor Vehicle Accidents Subtype: with another car Age: Event: Subtype: with a truck Age: Event: Subtype: on a motorcycle Age: Event: Subtype: on a bicycle Age: Event: Subtype: on public transit Age: Event: Subtype: as a pedestrian Age: Event: Trauma Type: Surgery Subtype: major Age: Event: Subtype: minor Age: Event: Subtype: childhood Age: Event: Subtype: skin cancer Age: Event: Subtype: cosmetic Age: Event: Subtype: surgical drain scars Age: Event: Subtype: bone or skin grafts Age: Event: Subtype: tissue biopsies Age: Event: Trauma Type: Fractures Subtype: treated by a cast Age: 16 Event: Left tibia fracture from soccer injury, treated with cast. Subtype: surgically treated Age: Event: Trauma Type: Repeated Sprains Age: Joint involved: Trauma Type: Falls Subtype: from height Age: Event: Subtype: onto tailbone Age: 10 Event: Fell on tailbone while playing, causing pain for two weeks. Trauma Type: Sports Injuries Age: 16 Event: Soccer injury resulting in a left tibia fracture. Trauma Type: Recreation Injuries Age: Event: Trauma Type: Childhood Injuries Subtype: bleeding events Age: Event: Subtype: crushing events Age: Event: Trauma Type: Assaults Subtype: no skin penetration Age: Event: Subtype: skin penetration Age: Event: Trauma Type: Concussions Subtype: something struck you Age: Event: Subtype: you struck something Age: Event: Trauma Type: Lacerations Subtype: glass Age: Event: Subtype: metal Age: Event: Subtype: to face Age: Event: Subtype: on chin Age: 8 Event: Fell and cut chin, requiring stitches. Subtype: other Age: Event: Trauma Type: Penetrating Wounds Subtype: weapon – note type Age: Event: Subtype: metal Age: Event: Subtype: wood / stick / sliver Age: Event: Trauma Type: Skin Lesions Subtype: cystic acne Age: Event: Subtype: shingles Age: Event: Subtype: chicken pox scar Age: Event: Trauma Type: Burns Subtype: heat/thermal Age: Event: Subtype: chemical Age: Event: Subtype: electrical Age: Event: Subtype: notable sunburn(s) Age: Event: Trauma Type: Animal Bites Subtype: note animal type Age: Event: **Step 13 – Scars** Patient has a scar on the left tibia from a fracture sustained at age 16. Patient also has a scar on the chin from a fall at age 8. **Step 14 – Most Significant Lifetime Event** Your first significant physical trauma in childhood: Fall on tailbone at age 10. The most significant physical trauma in your lifetime: Left tibia fracture at age 16. The injury which resulted in the most amount of bleeding: Chin laceration at age 8. The physical trauma which caused the greatest emotional trauma in your lifetime: None reported.