Neuropathy Screening

Please correct the errors described below.

Patient’s Name

Date

Please take a few minutes to answer the following questions about the feeling in your legs and feet. Check the appropriate boxes based on how you usually feel. Thank you.

1. Do you have diabetes?

Yes No

If Yes, what Type?

Type 1 Type 2

2. Do you have a Pacemaker?

Yes No

3. Have you had seizures in the last six months?

Yes No

4. Are your legs and/or feet numb?

Yes No

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

Yes No

6. Are your feet too sensitive to touch?

Yes No

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

Yes No

8. Do you ever have any prickling feelings in your legs and/or feet?

Yes No

9. Does it hurt when the bed covers touch your skin?

Yes No

10. When you get in the tub or shower, can you tell hot water from cold?

Yes No

11. Have you ever had an open sore on your foot?

Yes No

12. Has your doctor ever told you that you have diabetic neuropathy?

Yes No

13. Do you feel weak all over most of the time?

Yes No

14. Are your symptoms worse at night?

Yes No

15. Do your legs hurt when you walk?

Yes No

16. Are you able to sense your feet when you walk?

Yes No

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

Yes No

18. Have you ever had an amputation?

Yes No

New Orleans Podiatry Associates

2626 Jena Street, New Orleans, LA 70115 - t. 504.897.3627 f. 504.897.3339
3939 Houma Blvd, Bldg. 5, Ste. 217, Metairie, LA 70006 - t. 504.457.2300 f. 504.897.3339nolapodiatry.com | nolapodiatry@gmail.com

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