Take Our Brief Assessment To Schedule Your Free Nerve Screening

If you are a good candidate, someone from our team will contact you within one business day.

Full Name *

Phone *

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Which of the following neuropathy symptoms are you currently experiencing?

Please select all that apply.

Numbness

Tingling

Burning Sensation

Muscle Weakness

Pain

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Duration of Condition:

How long have you been experiencing your symptoms?

Less than a Year

1 - 2 Years

2 - 5 Years

5 - 10 Years

10+ Years

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Severity of Condition:

On a scale of 1-10 How would you rate the severity of your symptoms?

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Previous Treatments:

What have you done in the past to treat your neuropathy?

Please select all that apply.

Medication

Diet and Lifestyle Changes

Physical Therapy

Tens

Topical Treatments

Managing Root Cause

Other

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On a Scale of 1 – 10 with 1 being the lowest level of success and 10 being the highest, How well have you been able to manage your symptoms with your past treatments?

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Treatment Goals and Expectations:

What are your primary goals and expectations from a treatment for neuropathy?

Please select all that apply.

Pain or Symptom Reduction

Improved Mobility

Reducing Medication Reliance

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Comments and Concerns:

Is there any additional information you would like to share with the Doctor before we contact you?

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Neuropathy Protocol Survey

Someone from Axiom Chiropractic & Neuropathy will be contacting you from

(605) 275-2010

regarding your survey and to help you with scheduling an appointment. We can't wait to speak with you!

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