Please circle one number for each item |
Since the last time you filled these questions out: |
1. Are you experiencing any numbness in your hands and/or feet? |
Not at all |
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As Bad as it can be |
0 |
1 |
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10 |
2. Are you experiencing any tingling sensations in your hands and/or feet? |
Not at all |
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As bad as it can be |
0 |
1 |
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10 |
3. Are you experiencing any pain in your hands and/or feet? |
Not at all |
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As bad as it can be |
0 |
1 |
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10 |
4. Are you experiencing any difficulty walking? |
Not at all |
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As bad as it can be |
0 |
1 |
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10 |
5. Have you injured (bumped, cut, burned, etc) your hands and/or feet because of a lack of sensation? |
Not at all |
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As bad as it can be |
0 |
1 |
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10 |
6. Have you had any difficulty buttoning your shirt or tying your shoe-laces? |
Not at all |
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As bad as it can be |
0 |
1 |
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10 |
7. Has numbness/tingling/or pain interfered with your ability to perform normal work both inside and outside the home? |
Not at all |
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As bad as it can be |
0 |
1 |
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10 |