Neuropathy Treatment Feedback Survey
Please help us improve our care by providing feedback on your neuropathy treatment experience.
Full Name
*
First Name
Last Name
Age
*
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which type of neuropathy treatment did you receive?
*
Medication
Physical Therapy
Lifestyle Modification
Other
How long have you been receiving neuropathy treatment?
*
Please Select
Less than 1 month
1-3 months
3-6 months
More than 6 months
Please rate the improvement of your neuropathy symptoms since starting treatment.
*
No improvement
1
2
3
4
Significant improvement
5
1 is No improvement, 5 is Significant improvement
How satisfied are you with the care and support provided during your treatment?
*
1
2
3
4
5
Please indicate any side effects you experienced during your treatment (select all that apply):
Nausea
Dizziness
Fatigue
No side effects
Other
How easy was it to follow your treatment plan?
*
Very easy
Somewhat easy
Neutral
Somewhat difficult
Very difficult
Would you recommend this neuropathy treatment to others?
*
Yes
No
Not sure
Please provide any additional comments or suggestions regarding your treatment experience.
Signature (please sign to confirm your responses)
*
Submit Feedback
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