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About the Caretaker (you)

Sex: 

  Female       Male

How long have you been a caretaker for someone w/ Neuropathy Patient?

  Years       Months

I am a:

  Family   Friend Nurse   Doctor
  Other:

I am a caretaker for a:

  Female       Male

How long has the patient you take care of had Neuropathy Pain?

Years       Months

Symptoms

  Arm Pain
   Atrophy
   Back Pain
   Depression
   Difficulty Walking
   Difficulty Writing
   Dizziness
   Fatigue
   Foot Pain
   Hand Pain
   Headaches
   Hearing Disturbances
   Hypersensitivity
   IBS/ Gastrointestinal
   Insomnia/Sleep Disturbances
   Leg Pain
   Memory
   Migraines
   Muscle Spasms
   Nausea
   Neck Pain
   Optical Migraines
   Shoulder Pain
   Thyroid
   TMJ
   Vertigo
   Vision Disturbances
   Vomiting
   Weight Gain
   Weight Loss
  Other:

Do you feel you understand their condition:

  Yes      No

Do you feel you understand the pain level the patient is in:

  Yes      No

Do You Feel Depressed And Frustrated When You See Your Patient And Don’t Have Much Relief To Offer?

  Yes      No

Do you assist with:

  Showering
  Cooking
  Cleaning
  Pushing Wheelchair/Mobility
  Driving
  Daily Activities
  Organization

Are You Happy With Your Knowledge Of Neuropathy And Chronic Pain Sufferers?

  Yes      No

Please Feel Free To List Any Helpful Info You Feel Will Help Other Caretakers

Your contact information (optional)

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