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 :
DISABILITY SCORE:
12 NORMAL
DISABILITY SCORE:
13-27 MEDIUM
DISABILITY SCORE:
28-45 MODERATE
DISABILITY SCORE:
>46 SEVERE DISABILITY