First Name *

Last Name *

Phone *

Email *

1. When your symptoms flare up, how intense does it feel? *

0–2 (Barely noticeable)

3–4 (Uncomfortable but tolerable)

5–6 (Distracting — affects my focus)

7–8 (I have to stop what I’m doing)

9–10 (Overwhelming — it controls my day)

2. Which of these sensations have you experienced? *

Prickling / pins & needles

Burning feeling (like feet on fire)

Sharp, electric “zaps”

Numbness or loss of feeling

Cramping that comes out of nowhere

Deep aching that won’t go away

3. Where are you feeling this most often? *

Feet or toes

Lower legs

Symptoms traveling up the legs

Hands or fingers

Multiple areas

4. Has walking or standing become harder than it used to be? *

No noticeable change

I get sore faster

I avoid longer walks now

I’ve changed my lifestyle because of it

5. Have you noticed balance issues or feeling unsteady? *

No

Occasionally

Frequently — I have to be careful

I worry about falling

6. Are your symptoms affecting your sleep? *

No

Sometimes it’s hard to get comfortable

I wake up from leg/foot discomfort

I regularly lose sleep because of it

7. How long have you been dealing with these symptoms? *

Less than 3 months

3–12 months

1–3 years

Over 3 years

8. Have you tried any of the following? *

Prescription medications

Steroid injections

Over-the-counter pain relievers

Supplements or vitamins

“Just living with it”

9. Have your symptoms been gradually getting worse? *

No

Slightly

Yes — noticeably

Yes — significantly

10. What worries you most about these symptoms? *

It’s just part of aging

I’m afraid it will keep spreading

I don’t want to lose independence

I’m worried about long-term nerve damage

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