First Name
*
Last Name
*
Phone
Phone 2
Email
*
What symptoms do you have? (Check all that apply)
Numbness
Tingling
Burning
Coldness in feet
Balance problems
Loss of feeling
How long have you had these symptoms?
Less than 6 months
6 months to a year
1-3 years
Over 3 years
Are your symptoms getting worse?
Getting worse
Staying the same
Improving
Not sure
How would you rate your discomfort on most days?
Mild
Moderate
Severe
Disabling/affecting sleep or mobility
Do your symptoms interfere with any of the following (Check all that apply)
Sleep
Walking or balance
Standing for long periods
Driving
Work or household tasks
Enjoying hobbies
Have you tried any of the following treatments? Check all that apply)
Gabapentin/Lyrica/pain medications
Physical therapy
Chiropractic
Injections
Laser therapy
Supplements
Creams or lotions
Did any of the previous treatments provide meaningful relief?
Yes
A little
Not really
Not at all
Have you been diagnosed with any of the following?
Diabetes/Pre diabetes
Circulation problems
B12 deficiency
Thyroid issues
Autoimmune condition
Chemotherapy-induced neuropathy
Are you interested in learning if you qualify for advanced laser treatment?
Yes
No
Maybe
How soon are you wanting to get help?
As soon as possible
In the next 2 weeks
Just gathering information
Best time to call you? (Check all that apply)
Mornings
Afternoon
Early Evening
Is there anything else you want use to know about your condition?
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