Neuropathy Form | Dr. Urshan Health & Weight Loss Center

Complete This Survey To Discover If Our Neuropathy Protocol Treatments Are Right For You.

Here is what you should expect:

This Neuropathy Protocol Survey will provide our Doctors with some basic information about your condition so we can determine if you are a good candidate for an initial consultation and exam.

This survey is not intended to diagnose or give you any treatment advice concerning your condition.

Your responses to this survey will be reviewed by our Doctors and support team.

If we feel you may be a good candidate, someone from our team will reach out to you to answer any questions you may have and to help you schedule an consultation.

There is absolutely no obligation to schedule an consultation after this survey.

Once you have completed the survey you will have the option to schedule a call from our staff at a time that is convenient for you.

Thank you for your time,
‍
The Team at {practice-name}

Neuropathy Protocol Survey

Step 1 of 11

Before we begin, please provide your contact information.

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

Neuropathy Protocol Survey

Step 2 of 11

Which of the following neuropathy symptoms are you currently experiencing?

Please select all that apply.

Neuropathy Protocol Survey

Step 3 of 11

Duration of Condition:

How long have you been experiencing your symptoms?

Neuropathy Protocol Survey

Step 4 of 11

Severity of Condition:

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

Neuropathy Protocol Survey

Step 5 of 11

Previous Treatments:

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

Please select all that apply.

Neuropathy Protocol Survey

Step 6 of 11

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?

Neuropathy Protocol Survey

Step 7 of 11

Treatment Goals and Expectations:

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

Please select all that apply.

Pain or symptom reductionImproved mobilityReducing medication reliance

Neuropathy Protocol Survey

Step 8 of 11

Treatment Goals and Expectations:

What day of the week is the best for someone on our staff to contact you?

Please select all that apply.

Neuropathy Protocol Survey

Step 9 of 11

Treatment Goals and Expectations:

What time of day is the best for someone on our staff to contact you?

Please select all that apply.

Neuropathy Protocol Survey

Step 10 of 11

Comments and concerns:

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

Neuropathy Protocol Survey

Step 11 of 11

Someone from the team at {practice-name} will be contacting you from {phone-number}
regarding your survey and to help you with scheduling a consultation. We can't wait to speak with you!

By Clicking this box you give consent to be contacted by {practice-name} via SMS Texting, Email, and Phone