1. Do you often feel numbness or reduced sensation in your feet or toes? *

Never

Occasionally

Often

Everyday

2. Do your feet or hands feel unusually cold compared to the rest of your body? *

Never

Occasionally

Often

Everyday

3. Do you experience burning or tingling sensations that appear without a clear cause? *

Never

Occasionally

Often

Everyday

4. Do you notice weakness in your feet or ankles, such as difficulty lifting the front of your foot? *

No weakness

Mild weakness

Moderate weakness

Severe weakness

5. Do sharp, stabbing, or zapping sensations happen when you’re resting or lying down? *

Never

Occasionally

Often

Every Night

6. Do you lose balance easily or feel unsteady when walking in the dark or on uneven surfaces? *

No balance issues

Mild unsteadiness

Moderate unsteadiness

Severe unsteadiness

7. Have you noticed a reduced ability to feel temperature changes (hot vs cold) in your feet? *

No change

Mild reduction

Moderate reduction

Severe reduction

8. Do your symptoms get worse at night, especially when trying to sleep? *

Never

Occasionally

Often

Everyday

9. Do small injuries on your feet (cuts, blisters) take longer to heal than they used to? *

No, they heal normally

Slightly slower healing

Moderately slower healing

Much slower healing

Do your legs or feet feel tired, heavy, or fatigued even after minimal activity? *

Never

Occasionally

Often

Everyday