Neuropathy Risk Assessment Questionnaire
The following questions will help you understand whether your Nerve Health is at risk for peripheral neuropathy based on specific risk factors for nerve damage
Fill in your information with the complete and correct information!
Are Your Nerves At Risk?
Do you experience any of the following sensations in hands and/or feet?
Choose what applies to you
How bothersome have
these symptoms overall
been in the last two weeks?
Let us know on a scale from 1-10
Please select what
applies to you.
Where do you experience these sensations
Click on the areas where you
feel the sensations
feel the sensations
Clear all
YOUR TOTAL SCORE IS:
0Graphic
Please talk to your doctor and share the results of this questionnaire.
A total score > 4 (max. score is 14) may indicate peripheral neuropathy.
Is the distribution of these sensations symmetrical?
(E.g. have you felt these sensations in both feet or in both hands at the same time)
