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										As Bad as it can be
0	1	2	3	4	5	6	7	8	9	10
2. Are you experiencing any tingling sensations in your hands and/or feet?
Not at all										As bad as it can be
0	1	2	3	4	5	6	7	8	9	10
3. Are you experiencing any pain in your hands and/or feet?
Not at all										As bad as it can be
0	1	2	3	4	5	6	7	8	9	10
4. Are you experiencing any difficulty walking?
Not at all										As bad as it can be
0	1	2	3	4	5	6	7	8	9	10
5. Have you injured (bumped, cut, burned, etc) your hands and/or feet because of a lack of sensation?
Not at all										As bad as it can be
0	1	2	3	4	5	6	7	8	9	10
6. Have you had any difficulty buttoning your shirt or tying your shoe-laces?
Not at all										As bad as it can be
0	1	2	3	4	5	6	7	8	9	10
7. Has numbness/tingling/or pain interfered with your ability to perform normal work both inside and outside the home?
Not at all										As bad as it can be
0	1	2	3	4	5	6	7	8	9	10