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How Severe is Your Neuropathy?

See if you are a good candidate for drugless non surgical class 4 robotic laser treatment of neuropathy?

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Question 1 of 15

1. What symptoms do you have?

(Select all that apply)
A

Numbness

B

Tingling

C

Burning pain - worse at night

D

Sharp, electric, or shooting pains

E

Coldness in feet

F

Balance problems

G

Muscle weakness

H

Loss of feeling

I

None of the above

Question 2 of 15

2.How long have you been experiencing these symptoms?

 

(Select all that apply)
A

Less than 6 months

B

6 months to 1 year

C

1- 3 years

D

Over 3 years

Question 3 of 15

3. Are your symptoms...

(Select all that apply)
A

Getting worse

B

Staying the same

C

Improving

D

Not sure

Question 4 of 15

4. How would you rate your discomfort on most days?

(Select all that apply)
A

Mild

B

Moderate

C

Severe

D

Disabling/Affecting sleep or mobility

Question 5 of 15

5. Do your symptoms interfere with any of the following? 

(Select all that apply)
A

Sleep

B

Walking or balance

C

Standing for long periods

D

Driving

E

Work or household tasks

F

Enjoying hobbies

G

None of these

Question 6 of 15

6. Have you tried any of the following treatments?

(Select all that apply)
A

Gabapentin/Lyrica/Pain medications

B

Physical therapy

C

Chiropractic

D

Injections

E

Laser therapy

F

Supplements

G

Nothing yet

H

Other

Question 7 of 15

7. Did any of the previous treatments provide meaningful relief?

(Select all that apply)
A

Yes

B

A little

C

Not really

D

Not at all

Question 8 of 15

8. Have you been diagnosed with any of the following?

(Select all that apply)
A

Diabetes/Pre-diabetes

B

Circulation problems

C

B12 deficiency

D

Thyroid issues

E

Autoimmune conditions

F

Chemotherapy-induced neuropathy

G

None of the above

Question 9 of 15

9. Are you interested in learning whether you qualify for advanced laser treatment for neuropathy?

(Select all that apply)
A

Yes

B

Maybe

C

No

Question 10 of 15

10. How soon are you looking to get help?

(Select all that apply)
A

As soon as possible

B

In the next 1-2 weeks

C

Just gathering information

Question 11 of 15

11. Name

Question 12 of 15

12. Phone Number

Question 13 of 15

13. Email

Question 14 of 15

14. Best Time to Call You

(Select all that apply)
A

Morning

B

Afternoon

C

Evening

Question 15 of 15

Optional: Is there anything else you'd like us to know about your symptoms?

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