Diabetic Neuropathy 100% of survey complete. Question Title * 1. First name only Question Title * 2. Gender Female Male Question Title * 3. Age 20's 30's 40's 50's 60 and over Question Title * 4. Have you been diagnosed with painful diabetic neuropathy for at least one year? Yes No Question Title * 5. Would you rate your pain 4 or greater on a scale of 1-10 (1 being little pain) Yes No Question Title * 6. Would you be willing to apply a patch to your feet for pain management? Yes No Question Title * 7. Is your hemoglobin A1c (HbA1c or A1c) less than 11%? Yes No I don't know Question Title * 8. When was your last A1c done? 0-3 months ago 3-6 months ago 6-9 months ago Greater than 9 months ago Question Title * 9. Do you have fibromyalgia, arthritis, back pain or migraines? (mark all that apply) fibromyalgia back pain arthritis migraines Other (please specify) Question Title * 10. Are you taking any medications regularly to control your neuropathy pain? Yes No Question Title * 11. Are you taking any of the following to control any other pain (fibromyalgia, arthritis, back, etc)? Mark all that apply. Tylenol Advil Motrin Ibuprofen other Question Title * 12. What city are you located in? Question Title * 13. Email(So we can contact you if you're a good fit) Question Title * 14. Cell Phone number(So we can contact you if you're a good fit) Done
