100% of survey complete.

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1. First name only

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2. Gender

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3. Age

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4. Have you been diagnosed with painful diabetic neuropathy for at least one year? (Required.)

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5. Would you rate your pain 4 or greater on a scale of 1-10 (1 being little pain) (Required.)

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6. Would you be willing to apply a patch to your feet for pain management?

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7. Is your hemoglobin A1c (HbA1c or A1c) less than 11%? (Required.)

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8. When was your last A1c done?

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9. Do you have fibromyalgia, arthritis, back pain or migraines? (mark all that apply)

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10. Are you taking any medications regularly to control your neuropathy pain? (Required.)

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11. Are you taking any of the following to control any other pain (fibromyalgia, arthritis, back, etc)? Mark all that apply.

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12. What city are you located in?

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13. Email
(So we can contact you if you're a good fit) (Required.)

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14. Cell Phone number
(So we can contact you if you're a good fit) (Required.)

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