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NEW PATIENT FORM
SUFFERING FROM
NEUROPATHY?
No Medication
No Surgery
Take our 2 minute survey to see if you qualify for our $49 Neuropathy consultation package.
Step
1
of
13
7%
What is the problem you are experiencing? (Choose as many as you like.)
(Required)
Peripheral Neuropathy
Diabetic neuropathy
Autonomic neuropathy
Small fiber neuropathy
Ulnar neuropathy
Other
What is your pain / discomfort level on a scale of 0-10?
(Required)
0
1
2
3
4
5
6
7
8
9
10
Describe your pain/ discomfort. (Choose as many as you like.)
(Required)
Sharp
Aching
Burning
Stiffening
Numbness & Tingling
How long have you had this problem?
(Required)
0 - 3 months
3 - 12 months
1 - 3 years
Over 3 years
How many doctors have you seen for this problem?
(Required)
1
2
3
None
What have you tried in the past that has not corrected your problem? (Choose as many as you like.)
(Required)
Steroid Injections
Aspirin, Tylenol or Advil
Prescription Pain Medicine
Physical Therapy
Surgery
What activities are being negatively affected? (Choose as many as you like.)
(Required)
Walking
Sit to Stand
Squatting
Kneeling
What aspects of your life are being negatively impacted? (Choose as many as you like.)
(Required)
Marriage / Relationships
Ability to Exercise
Work
Mood
Sleep
On a scale of 0 - 10 how important is it for you to get this problem corrected?
(Required)
0
1
2
3
4
5
6
7
8
9
10
Is there anything else you’d like to share with us regarding your goals?
What is your first and last name?
(Required)
What is your phone number?
(Required)
What is your email address?
(Required)
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