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Questionnaire

Before You Visit

Subjective Peripheral Neuropathy Screen Questionnaire

Full Name:

Email:

Phone:

New Field:

Yes

No

New Field:

Yes

No

New Field:

Yes

No

Do you get muscle cramps in your legs and/or feet?

Yes

No

Do you ever have any prickling or tingling feelings in your legs or feet?

Yes

No

New Field:

Yes

No

When you get into the tub or shower, are you unable to tell the hot water from the cold water?

Yes

No

Do you ever have sharp, stabbing, shooting pain in your feet or legs?

Yes

No

Have you experienced an asleep feeling or loss of sensation in your legs or feet?

Yes

No

Do you feel weak when you walk?

Yes

No

Are your symptoms worse at night?

Yes

No

Do your lefts and/or feet hurt when you walk?

Yes

No

Are you unable to sense your feet when you walk?

Yes

No

Is the skin on your feet so dry it cracks open?

Yes

No

Have you ever had electric shock-like pain in your feet or legs?

Yes

No

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Take the First Step Towards Relief

Don't let neuropathy control your life. Contact us today to schedule a consultation and learn how we can help you reclaim your health and well-being.

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CONTACT US CALGARY CENTRE

151, 2515 – 90 Avenue SW
Calgary, AB T2V 0L8

Email: [email protected]

Tel: 403-452-4800

CONTACT US SASKATOON CENTRE

1269 – 8 Street E

Saskatoon, SK S7H 0S5

Email: [email protected]

Tel: 306-250-5221

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