Instructions:
Ask the patient to rate the severity of each symptom on a scale of 1 (mild) to 10 (most severe). Enter the score for each symptom in the column marked Presence/Severity. If symptoms have been present in the past, but not since the last visit, enter "currently absent". If the symptom has never been present, enter "always been normal".
Symptoms:
(1) pain, aching, or burning in hands, arms
(2) pain, aching, or burning in feet, legs
(3) "pins and needles" in hands, arms
(4) "pins and needles" in feet, legs
(5) numbness (lack of feeling) in hands, arms
(6) numbness (lack of feeling) in feet, legs
Recorded severity for each symptoms:
(1) never, always been normal
(2) currently absent
(3) if currently present, assigned a score from 1 (mild) to 10 (most severe)
|
Maximum Severity Score
|
Grade of Neuropathy
|
|
never or currently absent
|
0
|
|
1 – 3
|
1
|
|
4 – 6
|
2
|
|
7 – 10
|
3
|
