Neuropathy Symptom Score Questionnaire
Please complete this questionnaire to help assess your neuropathy symptoms and their impact on your daily life.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Contact Email
*
example@example.com
How long have you experienced neuropathy symptoms?
*
Please Select
Less than 6 months
6–12 months
1–2 years
More than 2 years
Please rate the severity of the following neuropathy symptoms over the past week:
*
Rows
None
Mild
Moderate
Severe
Numbness or tingling in feet
1
2
3
4
Numbness or tingling in hands
5
6
7
8
Burning or shooting pain
9
10
11
12
Loss of sensation to touch
13
14
15
16
Muscle weakness
17
18
19
20
Problems with coordination or balance
21
22
23
24
How often do you experience neuropathy symptoms?
*
Rarely
Occasionally
Frequently
Constantly
How much do your symptoms interfere with your daily activities?
*
Not at all
1
2
3
4
5
6
7
8
9
Extremely
10
1 is Not at all, 10 is Extremely
Please list any medications or treatments you are currently using for neuropathy symptoms.
Is there anything else you would like to share about your symptoms or experience?
Submit Questionnaire
Should be Empty: