Are Your Nerves Trying to Tell You Something?

1. Have you been diagnosed with neuropathy? If yes, what do you believe is the cause? (Check all that apply) *

Other:

2. Do you experience numbness, tingling, and/or a “pins and needles” feeling in your feet? *

Never

Occasionally

Frequently

Constantly

3. Do you feel sharp, burning, or shooting pains in your feet? *

No

Mild

Moderate

Severe

4. Do you have trouble balancing or feel unsteady when walking? *

Never

Occasionally

Frequently

Always

5. Can you feel the brake or accelerator pedal 100% when driving? *

Yes, always

Occasionally

No

6. Does your neuropathy disrupt your sleep? *

Yes, always

Occasionally

No

7. Have your symptoms gotten worse or started spreading to other areas? *

No

A little

Yes, gradually

Yes, quickly

Full Name *

Phone *

Email *

Your Score *

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