NEUROPATHY PATIENT FORMS

FREE NEUROPATHY CONSULTATION

Date

Full Name:

Driver License Expiration Date:

Cell Phone:

Email:

Birthdate:

***Social Security #:

Address:

City:

State:

Zip:

Occupation:

Retired?

Yes No

*Monthly Income $

Spouse Name:

How did you hear about us?

Check all your symptoms

Numbness/Tingling

Burning

Cramping

Freezing

Electric Shock Like Pain

Balance Problems

Which body parts are involved?

How long have you had these symptoms?

Is this condition interfering with any of the following:

Sleep

Recreational Activities

Work

Walking

Standing

Daily Activities

Select the types of doctors you have seen for these problems

Neurologist

Foot Doctor

Hand Doctor

Orthopedic

Family Doctor

Other:

If other, specify:

Have any previous methods worked for you? Check ALL that apply:

Bad results

Some results

Great results

Nothing changed

Didn't work very long

Still trying

How are these conditions affecting your: Check ALL that apply:

Job

Kids

Future ability

Marriage

Self Esteem

Sleep Time

Finances Freedom

Describe how these problems have affected your life. Give 3 examples (Select or Write below)

Time

Money

Happiness

Freedom

Sleep

Promotion

Other

If other please list

What are you most concerned with regarding these problems:

If your condition does not improve, what worries you most about the future?:

How would life be better for you without this problem? Please be specific:

List what conditions you are taking medicine for:

List any surgeries you have had and dates:

Are you a diabetic?

Yes No

Has your balance been getting worse?

Yes No

Are your symptoms like

Pain

Tingling

Numbness

Cramps

Electric shocks

worse at night?

Yes No

Can you feel the pedals in your car as well as you used to?

Yes No

Do you feel like your feet are wet or you are walking on cardboard?

Yes No

Can you walk barefoot?

Yes No

This program requires consistency, participation at home, and personal responsibility. How comfortable are you with that?

Very comfortable Somewhat comfortable Unsure Not comfortable

If this type of care is not covered by insurance and requires an out-of-pocket investment. Which best describes your mindset?

I understand and am prepared to invest in my health I have concerns but am open to discussing optio I am not sure I am ready for that level of commitment

Are you here primarily to gather information, or are you open to moving forward with care if it makes sense?

Information only Open to care Unsure

What would help you feel confident in your decision either way?

Neuropathy Care Support & Decision Questionnaire

Neuropathy treatment often involves important health decisions. In many cases, insurance provides limited or no coverage for certain treatments. Because of this, patients sometimes choose to involve a spouse, family member, or trusted person when reviewing their results and discussing care options.

The following questions help us understand who supports you so we can better assist you during your care.

1. Support System

Who knows that you are here today seeking help for your nerve condition?

Spouse / Partner

Adult Child

Other Family Member

Friend

Caregiver

No one yet

Name(s):

Relationship to you:

2. Impact on Others

Does your neuropathy condition affect anyone else in your life? For example: limiting activities together, needing help with mobility, transportation, or daily tasks.

Yes No

If yes, please explain briefly:

3. Health Care Decision Support

When making important healthcare decisions, do you usually discuss them with someone you trust?

Yes No

If yes, Name:

Relationship:

4. Financial Decision Support

Because insurance may not fully cover neuropathy treatment, some patients choose to involve a spouse, family member, or trusted individual when discussing treatment options and financial decisions.

Is there someone who helps you make financial decisions related to healthcare?

Yes No

If yes, Name:

Relationship:

5. Emergency Contact

Who should we contact in case of a medical emergency?

Name:

Relationship:

6. Participation in Your Care

If treatment is recommended and insurance coverage is limited, we encourage patients to bring someone they trust to their Examination visit so they can better understand the doctor's recommendations and help support the decision-making process.

Who would you feel comfortable bringing with you to review your results and treatment options?

Name:

Relationship:

What improvement would make the biggest difference in your life if your nerve condition improved?

Less pain or burning

Improved balance or walking

Sleep better

Stay independent

Avoid medications

Other:

Your information will be encrypted.