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Assessment Below To Reserve Your Spot

Take this short assessment to let us know how we can best help you.

Which symptoms you are suffering with?

Stabbing Pain

Burning

Numbness/Tingling

Pins/Needles

Balance Issues/Falls

Some of the above

None of the above

In the last 30 days, have your symptoms stayed the same, gotten better, or gotten worse?

Same

Better

Worse

How long have these symptoms been bothering you?

Less Than 1 Year

1-3 Years

4-6 Years

6+ Years

On a scale from 1-10 how bad is the pain in your feet and/or hands?

1

2

3

4

5

6

7

8

9

10

Are you taking pain medications that don't seem to get rid of the pain long term?

Yes

No

Do you have any of the following?

Diabetes

Alcoholism

Smoking

History of Chemotherapy

Some of the Above

None of the Above

Would you like to get relief from your symptoms?

Yes

No

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Sioux Falls, SD 57108

(605) 275-2010

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