DN4

Phil Rees or Mitch Bowd will ask you to complete the below form IF required. If you are unsure, please phone our rooms on (02) 4923 8999.

DN4

DD slash MM slash YYYY

Instructions

To estimate the probability of neuropathic pain, please answer yes or no for each item of the following questions.

Does the pain have the following characteristics: Burning?(Required)
Does the pain have the following characteristics: Painful cold?(Required)
Does the pain have the following characteristics: Electric shock?(Required)
Is the pain associated with the following symptom in the same area: Tingling?(Required)
Is the pain associated with the following symptom in the same area: Pins and needles?(Required)
Is the pain associated with the following symptom in the same area: Numbness?(Required)
Is the pain associated with the following symptom in the same area: Itching?(Required)
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