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Neuropathy Protocol Survey

Before we begin, please provide your contact information.

If you are a good candidate, someone from our team will contact you within one business day.

By Clicking this box you give consent to be contacted by Auslander Health Solutions via SMS Texting, Email, and Phone

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Neuropathy Protocol Survey

Which of the following neuropathy symptoms are you currently experiencing?

Please select all that apply.

Numbness

Tingling

Burning Sensation

Muscle Weakness

Pain

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Neuropathy Protocol Survey

Duration of Condition:

How long have you been experiencing your symptoms?

Less than a Year

1 - 2 Years

2 - 5 Years

5 - 10 Years

10+ Years

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Neuropathy Protocol Survey

Severity of Condition:

On a scale of 1-10 How would you rate the severity of your symptoms?

1

2

3

4

5

6

7

8

9

10

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Neuropathy Protocol Survey

Previous Treatments:

What have you done in the past to treat your neuropathy?

Please select all that apply.

Medication

Diet and Lifestyle Changes

Physical Therapy

Tens

Topical Treatments

Managing Root Cause

Other

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Neuropathy Protocol Survey

On a Scale of 1 – 10 with 1 being the lowest level of success and 10 being the highest, How well have you been able to manage your symptoms with your past treatments?

1

2

3

4

5

6

7

8

9

10

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Neuropathy Protocol Survey

Treatment Goals and Expectations:

What are your primary goals and expectations from a treatment for neuropathy?

Please select all that apply.

Pain or Symptom Reduction

Improved Mobility

Reducing Medication Reliance

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Neuropathy Protocol Survey

Are you serious about finding real solutions for your neuropathy and improving your quality of life?

Yes

No

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Neuropathy Protocol Survey

Comments and Concerns:

Is there any additional information you would like to share with the Doctor before we contact you?

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