Complete the below survey and we will let you know if you can be a candidate For Neuropathy Treatment
Please complete the questionaire below. Any further questions or to see if you qualify by phone, contact our office at
to schedule an initial consultation
Please check any or all of the primary pain you are experiencing:
How long have you had the pain?
Less than a month
More than 6 wks
More than 6 months
More than 1 yr
Check any or all of the modifiers that most closely describe your pain.
Which best describes the frequency of your pain?
Intermittent (0-25% of day)
Occasional (26-50% of day)
Frequent (51-75% of day)
Constant (76-100% of day)
Have you already contacted a doctor about your pain
Are You Taking Pain Medication?
My condition and pain has affected my activities as follows
Interrupted Sleep at night
Have you been diagnosed with any of the following
Restless Legs Syndrome
Carpal Tunnel Syndrome
Tingling Sensations In Your Feet, Legs, or Hands
Which more closely describes your pain level by time of day:
When is your pain at its worst? Describe how you feel and are affected
When was the last time you felt really great?:
If there is a way to relieve your pain with one of our advanced non-surgical treatment programs, are you interested in scheduling a consult with our doctor?
What is the best time to contact you?: