Diabetic Nerve pain Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Do you feel tingling, pain, or numbness in your feet or hands? YesNoNot sureDo you have bloating, constipation, diarrhea, heartburn, or nausea? YesNoNot sureDo you frequently have high blood sugar? YesNoNot sureHave you had diabetes for a long time?No, 2 years or lessYes, 3 to 10 yearsYes, 10 years or moreYes, 10 years or moreYesNoNot sureAre you over 40? YesNoDo you have high cholesterol and triglycerides?YesNoNot sureDo you have high blood pressure? YesNoNot sure Do you smoke or drink alcohol? YesNoSometimesDo you have pain in legs? YesNoSometimesDo you wake up in the middle of night for pain in legs or elsewhere?YesNoSometimesAre you unable to walk or exercise because of pain?YesNoSometimesCommentSubmit