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Neurometer Log

Neuropathy Risk Assessment Questionnaire

The following questions will help you understand whether your Nerve Health could be at risk based on certain risk factors for nerve damage.

In case you have a concern or would like to get a medical diagnosis, please seek advice from your doctor. This is not a self-diagnosis tool and will not provide a definitive diagnosis.

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ARE YOUR NERVES AT RISK?

FILL IN YOUR PROFILE BELOW WITH COMPLETE AND CORRECT INFORMATION

Full Name*

E-mail*

Phone Number*

By providing my information through this form, I hereby consent to the collection and processing of my personal data by Procter & Gamble ("P&G") and its affiliates for neuropathy risk factors check, research and publication, and product claim development. I also agree to receiving further marketing materials and promotion information regarding Neurobion and other P&G brands. I acknowledge and understand that my personal data will be retained by P&G until such purpose is accomplished.

I also acknowledge and agree that P&G could give my data to its specific affiliates and third-party service providers for further processing of the purpose stated above. I also confirm that I am at least 18 years old and I have read and agree to the Terms and Conditions and P&G Privacy Policy (pg.com)

I understand that I have the rights to withdraw my consent to receive marketing materials from P&G at any time by unsubscribing to the communications sent by P&G or by contacting P&G at 0800 1402 869.

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Before we start, tell us more about you!

Please consider, that is not a self-diagnosis tool and will not replace a medical examination. The test outcome is intended to provide an idea on a potential risk for nerve damage. To receive a precise diagnosis please see your doctor for a medical examination.

YOUR LIFESTYLE

Are you on a vegetarian diet?

Please consider, that is not a self-diagnosis tool and will not replace a medical examination. The test outcome is intended to provide an idea on a potential risk for nerve damage. To receive a precise diagnosis please see your doctor for a medical examination.

YOUR LIFESTYLE

Do you exercise on a regular basis?

(3x or more in a week)

Please consider, that is not a self-diagnosis tool and will not replace a medical examination. The test outcome is intended to provide an idea on a potential risk for nerve damage. To receive a precise diagnosis please see your doctor for a medical examination.

YOUR LIFESTYLE

Do you smoke?

Please consider, that is not a self-diagnosis tool and will not replace a medical examination. The test outcome is intended to provide an idea on a potential risk for nerve damage. To receive a precise diagnosis please see your doctor for a medical examination.

BACKGROUND

Is there anyone in your immediate family who has been diagnosed with diabetes?

Please consider, that is not a self-diagnosis tool and will not replace a medical examination. The test outcome is intended to provide an idea on a potential risk for nerve damage. To receive a precise diagnosis please see your doctor for a medical examination.

HOW OBSERVANT ARE YOU?

Do you ever feel one of the following sensations in your hands and feet?

Please consider, that is not a self-diagnosis tool and will not replace a medical examination. The test outcome is intended to provide an idea on a potential risk for nerve damage. To receive a precise diagnosis please see your doctor for a medical examination.

HOW OBSERVANT ARE YOU?

When it comes to these sensations, I feel them on both hands or both feet at the same time.

Please consider, that is not a self-diagnosis tool and will not replace a medical examination. The test outcome is intended to provide an idea on a potential risk for nerve damage. To receive a precise diagnosis please see your doctor for a medical examination.

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Please consider, that is not a self-diagnosis tool and will not replace a medical examination. The test outcome is intended to provide an idea on a potential risk for nerve damage. To receive a precise diagnosis please see your doctor for a medical examination.

HOW OBSERVANT ARE YOU?

How long have you been experiencing these sensations?

Please consider, that is not a self-diagnosis tool and will not replace a medical examination. The test outcome is intended to provide an idea on a potential risk for nerve damage. To receive a precise diagnosis please see your doctor for a medical examination.

HOW OBSERVANT ARE YOU?

Is the sensation worse at night?

Please consider, that is not a self-diagnosis tool and will not replace a medical examination. The test outcome is intended to provide an idea on a potential risk for nerve damage. To receive a precise diagnosis please see your doctor for a medical examination.

HOW OBSERVANT ARE YOU?

Do you take painkillers for these sensations?

Please consider, that is not a self-diagnosis tool and will not replace a medical examination. The test outcome is intended to provide an idea on a potential risk for nerve damage. To receive a precise diagnosis please see your doctor for a medical examination.