Understand Your Pain Type
In the past 2 weeks how much has your peripheral neuropathy
1. Limited your ability to
walk?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
2. Limited your ability to run?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
3. Limited your ability to climb up or down stairs?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
4. When standing made doing things more difficult?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
5. Limited your balance when standing / walking?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
6. Limited how far you are able to walk?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
7. Increased the effort needed for you to walk?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
8. Made it necessary for you to use support when walking indoors, eg holding on to furniture, using a cane, etc?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
9. Made it necessary for you to use support when walking outdoors, eg using a cane or walker, etc?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
10. Slowed down your walking?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
11. Affected how smoothly you walk?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
12. Made you need to use more concentration when you walk?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
WALKING SCALE QUESTIONAIRE SCORE TOTAL :
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
2. Limited your ability to run?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
3. Limited your ability to climb up or down stairs?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
4. When standing made doing things more difficult?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
5. Limited your balance when standing / walking?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
6. Limited how far you are able to walk?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
7. Increased the effort needed for you to walk?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
8. Made it necessary for you to use support when walking indoors, eg holding on to furniture, using a cane, etc?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
9. Made it necessary for you to use support when walking outdoors, eg using a cane or walker, etc?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
10. Slowed down your walking?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
11. Affected how smoothly you walk?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
12. Made you need to use more concentration when you walk?
Not at all A little 25% Moderately 50% Quite a bit 75% Extremely 100%
WALKING SCALE QUESTIONAIRE SCORE TOTAL :