1

Are you legs and/or feet numb?

□ Yes □ No

2

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

□ Yes □ No

3

Are your feet too sensitive to touch?

□ Yes □ No

4

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

□ Yes □ No

5

Do you ever have any prickling feelings in your legs or feet?

□ Yes □ No

6

Does it hurt when the bed covers touch your skin?

□ Yes □ No

7

When you get into the tub or shower, are you able to tell the hot water from the cold water?

□ Yes □ No

8

Have you ever had an open sore on your foot?

□ Yes □ No

9

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

□ Yes □ No

10

Do you feel weak all over most of the time?

□ Yes □ No

11

Are your symptoms worse at night?

□ Yes □ No

12

Do your legs hurt when you walk?

□ Yes □ No

13

Are you able to sense your feet when you walk?

□ Yes □ No

14

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

□ Yes □ No

15

Have you ever had an amputation?

□ Yes □ No