If your neuropathy symptoms improved, what would change for you most?

Select all that apply.

If your neuropathy symptoms improved, what would change for you most?

I could walk or stand longer without discomfort

I would sleep better and feel more rested

I’d feel steadier and safer with my balance

I could get back to the activities I enjoy

I’d have less burning, tingling, or numbness

I’d feel more in control of my health and day-to-day life

I’m not sure, but I want help figuring out the best next step

I’d get to do more with family.

Which symptoms feel most true for you right now?

Select all that apply.

Which symptoms feel most true for you right now?

Numbness

Tingling or pins-and-needles

Burning or hot sensations

Sharp, shooting, or stabbing pain

Weakness or heaviness

Balance issues or unsteadiness

I’m not sure

Where do you feel symptoms most often?

Select all that apply.

Where do you feel symptoms most often?

Feet or toes

Legs

Hands or fingers

Arms

Both feet and hands

Hard to pinpoint

Fear of amputation

I'm not sure

What made you decide to look for help now?

Select all that apply.

What made you decide to look for help now?

It’s been getting worse

It’s affecting my daily life

It’s affecting my sleep or energy

I’m worried about long-term changes

I want to avoid surgery

Someone I trust recommended your clinic

Fear of amputation

I'm not sure

What have you tried so far to get relief?

Select all that apply.

What have you tried so far to get relief?

I haven’t tried much yet

Medications

Physical therapy or rehab

Injections or procedures

Supplements or lifestyle changes

Home devices or at-home treatments

How often do your symptoms affect you?

Select one.

How often do your symptoms affect you?

Every day

Most days of the week

A few times a week

A few times a month

Only occasionally, but it worries me

It comes and goes and I can’t predict it

Where should we send your results?

First Name

Last Name

Phone

e.g. (555) 555-5555

Email

e.g. name@example.com