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Age Now

Age When Developed Neuropathy Condition

Type of Neuropathy Condition you have

Sex

  Female       Male

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:

What Caused your Neuropathy

  Auto Accident
  Surgery
  Work
  Accident
  Unknown
  Home Injury
  Cancer Chemo/ Radiation
  Other:

How many doctors did you see prior to your diagnosis

  1-3
  4-6
  6-10
  10-15
  16-20
  20+

How long did it take for your doctor(s) to diagnose you?

  >6 months
  6-12 Months
  12-24 Months
  <24 Months

Do you have a caretaker

  Yes      No

If Yes, Are they related to you?

  Yes      No

Do you use assisted Mobility Devices?

  Cane
  Wheelchair
  Scooter
  Other:

Do you have private or group health insurance

  Yes      No

Are you on Medicare

  Yes      No

Are you on disability

  Short Term
  Long Term
  Social Security (Permanent)
  Applied/Waiting for Response
  Applied and Turned Down

How do you describe your pain

  Burning
  Constant
  Cutting
  Numbing
  Dull
  Electric
  Intermittent
  Stabbing
  Sharp
  Shooting
  Other:

Have you been prescribed medication for

  Migraines
  Pain
  Heart
  Thyroid
  Vitamins
  Depression
  Low Blood Pressure
  High Blood Pressure
  Vertigo
  Nausea
  Other:

Have you had therapy

  Physical
  Occupational
  Mental
  Home Care
  Hydrotherapy
  Massage
  Chiropractic
  Other:

Are you happy with your healthcare providers knowledge of your Neuropathy condition

  Yes      No

Would you refer any of your doctors to other Neuropathy patients

  Yes      No

If yes, please list name, specialty, city and state

Please feel free to list any other helpful information you feel will help other patients

Your contact information (optional)

If you are having trouble submitting your answers.
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