Peripheral Nervous System Functions Survey
Please complete this survey to help us assess various aspects of your peripheral nervous system functions. Your responses will remain confidential.
Full Name
*
First Name
Last Name
Age
*
Email Address
*
example@example.com
Have you experienced any of the following symptoms recently?
*
Numbness or tingling in hands or feet
Muscle weakness
Unsteady gait or balance issues
Burning or stabbing pain in limbs
Muscle cramps or spasms
Other
How would you rate your overall muscle strength?
*
1
2
3
4
5
Please indicate the frequency of the following sensations in your extremities (hands/feet):
*
Rows
Never
Rarely
Sometimes
Often
Always
Numbness
1
2
3
4
5
Tingling
6
7
8
9
10
Burning sensation
11
12
13
14
15
Pins and needles
16
17
18
19
20
Do you have any difficulty with fine motor tasks (e.g., buttoning a shirt, writing)?
*
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Please indicate if you have noticed any changes in the following autonomic functions:
*
Rows
No Change
Mild Change
Significant Change
Sweating patterns
21
22
23
Bowel or bladder habits
24
25
26
Heart rate or blood pressure
27
28
29
Temperature sensitivity
30
31
32
Have you experienced any abnormal reflexes (such as exaggerated or diminished reflexes)?
*
No
Yes, exaggerated reflexes
Yes, diminished reflexes
Not sure
On a scale of 1 to 10, how much do these symptoms affect your daily activities? (1 = Not at all, 10 = Severely)
*
Not at all
1
2
3
4
5
6
7
8
9
Severely
10
1 is Not at all, 10 is Severely
Please describe any other symptoms or relevant information regarding your peripheral nervous system functions.
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