Thanks For Scheduling Your Appointment!

Thanks For Your Interest, !

One of our team will be in touch to schedule your appointment.

In order for us to best prepare for your appointment, please complete this brief survey below within the next 10 minutes:

What neuropathy symptoms are you experiencing? (Check all that apply) *

Pain

Burning

Numbness

Tingling

Pins & Needles

Weakness or loss of sensation in the affected areas

Muscle cramps or spasms

Increased sensitivity to touch or temperature changes

Difficulty with coordination and balance

Loss of reflexes

Dizziness or lightheadedness

Other

On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain?

Have you been diagnosed with neuropathy in the past? *

Yes

What areas of your life are affected by the pain? Choose all options that apply. *

Maintaining a safe environment

Communication

Breathing

Eating & drinking

Washing & dressing

Mobilization

Working & playing

Expressing sexuality

Sleeping

Daily parenting

Finances

Household chores

Self worth/value

Physical well-being

Emotional health

Other

How committed are you to fixing your pain? *

Very Committed

Somewhat Committed

Neutral

Not ready to commit yet

PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: I will NOT miss my appointment because I respect your time and I understand it's not fair to others who would schedule in my place if I don't show up. *

Yes

First Name *

Last Name *

Email *

Phone *

Aligned Health and Wellness

663 Gralin Street, Kernersville 27284 | (336) 996-7007