Neurological and Vascular Patient Questionnaire Name* Name Email* Date* Date Format: MM slash DD slash YYYY For any YES answer, please notify the Doctor.Do you suffer from neck pain with pain in your shoulder, arms or hands?NOYESCommentDo you have weakness, numbness or burning in your shoulder, arms, or hands?NOYESCommentDo your hands or arms fall asleep regularly?NOYESCommentDo you have reduced feeling (sensation) or swelling in your hands or arms?NOYESCommentDo you suffer from a loss of handgrip?NOYESCommentDo you suffer from back pain with pain in your buttocks, legs or feet?NOYESCommentDo your legs or feet fall asleep regularly?NOYESCommentDo you have reduced feeling (sensation) or swellings in your legs, feet?NOYESCommentsDo you suffer from cold hands or feet?NOYESCommentDo you suffer from headaches, dizziness or memory loss?NOYESCommentDo you have difficulty maintaining your balance?NOYESCommentDo you have difficulty maintaining your balance?NOYESCommentDo you suffer from vertigo or blurred?NOYESCommentDo you suffer from a reduced hearing capacity?NOYESCommentDo you suffer from ringing in your ears?NOYESCommentDo you have bladder or bowel control problems on a regular basis?NOYESComment
