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Questionnaire

Please take a few minutes to complete the Subjective Peripheral Neuropathy Screen Questionnaire below to see if you potentially have peripheral neuropathy.

  1. Do you ever have legs and/or feet that feel numb? Yes | No
  2. Do you ever have any burning pain in your legs and/or feet? Yes | No
  3. Are your feet too sensitive to touch? Yes | No
  4. Do you get muscle cramps in your legs and/or feet? Yes | No
  5. Do you ever have any prickling or tingling feelings in your legs or feet? Yes | No
  6. Does it hurt at night when the covers touch your skin? Yes | No
  7. When you get into the tub or shower, are you able to tell the hot water from the cold water? Yes | No
  8. Do you ever have any sharp, stabbing, shooting pain in your legs or feet? Yes | No
  9. Have you experienced an asleep feeling or loss of sensation in your legs or feet? Yes | No
  10. Do you feel weak when you walk? Yes | No
  11. Are your symptoms worse at night? Yes | No
  12. Do your legs and/or feet hurt when you walk? Yes | No
  13. Are you unable to sense your feet when you walk? Yes | No
  14. Is the skin on your feet so dry that it cracks open? Yes | No
  15. Have you ever had electric shock-like pain in your feet or legs? Yes | No

If you answer yes to three or more questions, you may have Peripheral Neuropathy.

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3:30 pm-6:30 pm

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