Neuropathy Screening DFW | Numbness, Tingling in Feet & Hands

Do you have any of the following?
Select all that apply

Numbness or tingling in your extremities Slowed reflexes Burning or freezing in your hands or feet Muscle weakness Sharp pain None of the above

Where is your pain?
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Have you had
Select all that apply

Loss of bladder control Changes in blood pressure Gastrointestinal issues None of the above

Do you now or have you ever had any of the following?
Select all that apply

Autoimmune disorders Diabetes Heavy metal or toxic chemical exposure Vitamin B or E deficiency Bone marrow, kidney or liver disease Infections such as shingles, hepatitis C, Lyme disease or other viral or bacterial infections Trauma caused by falls, car accidents or sports injuries None of the above

Have you ever been diagnosed with Neuropathy?

Yes No

Are you taking any prescription medication for your pain?

Yes No

Are you interested in a treatment option that is drug free and non-surgical?

Yes No

Your answers indicate:

You may be a candidate for treatment, but further information is needed to make an accurate diagnosis.

We would like to offer you a voucher for a free consultation so that we can better understand the source of your pain and provide you with the information you need to make an informed healthcare decision.

Who do we send the voucher to?

First Name

Last Name

Email

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