Form Cms-R-131 - Application For Peripheral Neuropathy Treatment Page 2
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10What do you think is causing your problem?:
Names of all doctors you have seen for these problems and treatment you received:
Have your symptoms: □ Improved □ Worsened □ Stayed the Same
List anything that makes your condition worse:
List anything that makes your condition better:
How would you describe the symptoms? Please check all that apply:
□ Aching Pain
□ Numbness
□ Hot sensation
□ Cramping
□ Stabbing Pain
□ Tingling
□ Throbbing Pain
□ Swelling
□ Sharp Pain
□ Pins and Needles Pain
□ Dead Feeling
□ Burning
□ Tiredness
□ Heavy Feeling
□ Cold Hands/Feet
□ Electric Shocks
Is this condition interfering with any of the following?
□ Sleep □ Work □ Daily Activities □ Housework □ Recreational Activities □ Walking □ Standing □ Shopping
Social History
Do you smoke?
□ Yes □ No
If yes, how many packs/daily:
Do you drink? □ Yes □ No If yes, how many drinks/week:
Do you exercise regularly? Yes No If yes, describe what type and how often:
Current Pain Levels
How would you rate your pain/discomfort in the last week:
None
Worst Possible
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If you had to accept some level of discomfort after completion of treatment, what would be an acceptable level?
None
Worst Possible
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0 votes
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