Have you been diagnosed with peripheral neuropathy by a licensed healthcare professional?
*
Yes
No
Not sure
Neuropathy Diagnosis
Have you been diagnosed with diabetes?
*
Yes
No
Not sure
Diabetes History
Which of the following symptoms are you currently experiencing?
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Numbness
Burning
Tingling
Pins and needles
Tightness
Electric sensation
Stabbing pain
Hot or cold sensation
Current Symptoms
Has sensation in your feet decreased compared with how it used to feel?
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Yes
No
Not sure
Reduced Sensation
Has your balance or steadiness worsened?
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Yes
No
Not sure
Balance Changes
Are your symptoms worse at night?
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Yes
No
Not sure
Symptoms Worse at Night
Are your symptoms present most days?
*
Yes
No
Not sure
Symptoms Present Most Days
Are you currently using medication for nerve-related pain?
*
Yes
No
Not sure
Nerve Pain Medication
Did your symptoms begin during or after chemotherapy?
*
Yes
No
Not sure
Chemotherapy History
How soon would you like to explore your options?
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Within the next 2 weeks
Within the next 30 days
I am researching my options
Not a priority right now
Readiness Timeline
Do you live in Fort Collins or within driving distance of our office?
*
Yes
No
Not sure
Service Area
Have you tried treatment for these symptoms before?
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Yes
No
Not sure
Previous Treatment
How much are these symptoms affecting your daily life?
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A lot, they affect my walking, sleep, or daily activities
Somewhat, they bother me but I can still manage
A little, they are noticeable but not severe
Not much right now
Daily Life Impact
Would you be open to a brief phone consultation to discuss whether an in-office evaluation may be appropriate?
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Yes, I would like to speak with someone
Maybe, I would like more information first
No, I am only researching right now
Open to Phone Consultation
Are you currently enrolled in Medicare?
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Yes
No
Not Sure
Medicare Enrollment
Are you currently enrolled in Medicaid?
*
Yes
No
Not Sure
Medicaid Enrollment
Your screening is almost complete. Enter your details below so we can show your result and next step.
Full Name
*
Email
*
Phone
*
Screening Complete
Thank you for completing the screening
Based on your answer, this program may not be the right fit at this time.
If you have questions, please contact our office directly at (970) 300-2166.
Please submit your screening so our team can process your response.