Do you currently experience peripheral neuropathy pain, burning, or numbness?
*
Yes
No
Do you currently take medications for peripheral neuropathy such as Lyrica or Gabapentin
*
Yes
No
Do the doctors know what caused your neuropathy?
*
Yes
No
How committed are you to fixing your neuropathy TODAY?
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Very Committed
Somewhat Committed
Neutral
Not ready to commit
PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: "I will NOT miss my appointment once it is scheduled because I respect your time and I understand it's not fair for others who have scheduled in my place if I don't show up."
*
Yes
No