Peripheral Neuropathy Questionnaire

Do You Have Peripheral Neuropathy?

If you have answered “Yes” to multiple questions, then you may be a good candidate for treatment. Contact LifeWorks Family Chiropractic and Wellness to schedule your FREE Certified Peripheral Neuropathy Workshop and find the relief you’ve been searching for!

250-868-4880

Medical Assessment Form

1. Do you ever have legs and/or feet that feel numb? *

Yes No

2. Do you ever have any burning pain in your legs and/or feet? *

Yes No

3. Are your feet too sensitive to touch? *

Yes No

4. Do you get muscle cramps in your legs and/or feet? *

Yes No

5. Do you ever have any prickling or tingling feelings in your legs or feet? *

Yes No

6. Does it hurt at night or when the covers touch your skin? *

Yes No

7. When you get into the tub or shower, are you unable to tell the hot water from the cold water with your feet? *

Yes No

8. Do you ever have any sharp, stabbing, shooting pain in your feet or legs? *

Yes No

9. Have you experienced an asleep feeling or loss of sensation in your legs or feet? *

Yes No

10. Do you feel weak when you walk? *

Yes No

11. Are your symptoms worse at night? *

Yes No

12. Do your legs and/or feet hurt when you walk? *

Yes No

13. Are you unable to sense your feet when you walk? *

Yes No

14. Is the skin on your feet so dry that it cracks open? *

Yes No

15. Have you ever had electric shock-like pain in your feet or legs? *

Yes No

Contact Information

Full Name * Phone * Email * Postal Code * How did you hear about us? *

Would you like a doctor to contact you? *

Yes No

Book Your Spot at Our Free Workshop Today!

Don’t let peripheral neuropathy hold you back any longer. Contact us to secure your place at our upcoming workshop and take the first step toward lasting relief.

Peripheral Neuropathy Relief Kelowna BC | (250) 868-4880

LifeWorks Family Chiropractic
101-1740 Gordon Dr
Kelowna, BC V1Y 3H2
Phone: (250) 868-4880

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