Fill out the survey Prior to Your Neuropathy Reversal Appointment
First Name
*
Last Name
*
Phone
*
Email
*
Neuropathy Symptoms (Check all that Apply)
*
Foot Pain
Hand Pain
Low Back Pain
Neck Pain
Foot Numbness
Hand Numbness
Diabetes
High Cholesterol
High/Low Blood Pressure
Pacemaker/Defibrillator
Herniated Disc
Budging Disc
Spinal Stenosis
Degenerative Disc
Vascular Problems
Leg Pain
Plantar Fasciitis
Morton's Neuroma
Cancer
Chemotherapy
Arthritis in Hands
Arthritis in Feet
Sciatica
Pinched Nerve
Poor Circulation
Joint Replacement
Foot Surgery
Poor Wound Healing
Excessive thirst or urination
Is your Diabetes Managed with Medications?
Yes
No
In order of importance, list 2-4 health problems you are most interested in getting corrected
List approximately how long you have noticed these problems
Is there a certain time of day any of these problems are better or worse?
What have you used for these problems (Check all that apply)
Gabapentin
Neurotin
Lyrica
Cymbalta
Physical Therapy
Pain Medications
Aleve
Tylenol
Ibprofen
Mortrin
Chiropractic
Massage Therapy
Injections
Creams
Is your balance and walking affected? If yes, explain
When were your last blood labs?
Have your symptoms
Improved
Worsened
Stayed the Same
List anything that makes your condition worse
List anything that makes your condition better
How would you describe your symptoms (Check all that apply)
Aching Pain
Numbness
Hot Sensation
Cramping
Stabbing Pain
Tingling
Throbbing Pain
Swelling
Sharp Pain
Pins & Needles Pain
Dead Feeling
Burning
Tiredness
Heavy Feeling
Cold Hands/Feet
Electric Shocks
Do you smoke?
Yes
No
Do you exercise regularly
Daily
Moderately
No
Do you drink?
Often
Sometimes
Never
How would you rate your pain last week? (10 being the worst)
1
2
3
4
5
6
7
8
9
10
What are you most concerned about regarding your problem?
Where do you picture yourself in the next 1-3 years if this problem is not taken care of?
Would life be different/better without this problem? Be specific
What do you desire most to get from working with us?
What would this mean to you?