Free Neuropathy Test

Person Information

First Name *

Last Name *

Email *

Phone 1 *

Street Address 1 *

City *

State *

Postal Code *

You are suffering from pain due to injury or disease of the nervous system.
This pain may be of several types. You may have spontaneous pain, i.e.
pain in the absence of any stimulation, which may be long-lasting or occur as brief attacks.
You may also have pain provoked or increased by brushing, pressure, or contact with cold in the painful area.

You may feel one or several types of pain.
This questionnaire has been developed to help your doctor to
better evaluate and treat various types of pain you feel.

We wish to know if you feel spontaneous pain, that is pain without any stimulation.

For each of the following questions, please select the number that best describes
your average spontaneous pain severity during the past 24 hours.

Select the number 0 if you have not felt such pain (select one number only).

Q1. Does your pain feel like burning? *

Q2. Does your pain feel like squeezing? *

Q3. Does your pain feel like pressure? *

Q4. During the past 24 hours, your spontaneous pain has been present *

	Permanently
	Between 8 and 12 hours
	Between 4 and 7 hours
	Between 1 and 3 hours
	Less Than 1 hour

We wish to know if you have brief attacks of pain.
For each of the following questions, please select the number that
best describes the average severity of your painful attacks during the past 24 hours.
Select the number 0 if you have not felt such pain (choose one number only).

Q5. Does your pain feel like electric shocks? *

We wish to know if you feel pain provoked or increased by
brushing, pressure, contactwith cold or warmth on the painful area.
For each of the following questions, please select the number that best
describes the average severity of your provoked pain during the past 24 h.

Select the number 0 if you have not felt such pain (choose one number only).

Q6. Does your pain feel like stabbing? *

Q7. During the past 24 hours, how many of these pain attacks have you had?
Select the response that best describes your case.

	More Than 20
	Between 11 and 20
	Between 6 and 10
	Between 1 and 5
	No pain attack

Q8. Is your pain provoked or increased by brushing on the painful area?

Q9. Is your pain provoked or increased by pressure on the painful area?

Q10. Is your pain provoked or increased by contact
with something cold on the painful area?

We wish to know if you feel abnormal sensations in the painful area.
For each of the following questions, please select the number that best describes
the average severity of your abnormal sensations during the past 24 hrs.

Select the number 0 if your have not felt such sensation (circle one number only).

Q11. Do you feel pins and needles?

Q12. Do you feel tingling? *

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