Questionnaire Questionairre 1. Have you ever been diagnosed with diabetes? Yes No 2. Are your feet cold, blue, swollen, or have you ever been told you have a circulation problem? Yes No 3. Do you have feelings of electrical shock, or bugs crawling on your legs? Do you have numb feet or legs? Yes No 4. Do you have bumps on the side of your big or little toe? Yes No 5. Do you have heel or arch pain first thing in the morning or after you have been resting? Yes No 6. Do you have thick, black, yellow, crumbly, or ugly nails? Yes No 7. Do you have pain in the balls of your feet? Yes No 8. Do you have calloused, scaly, or cracked feet? Yes No 9. Do you get ingrown toenails? Yes No 10. Do you have sores on your feet that are slow healing? Yes No Name* First Last Phone*Email* Any Comments Δ
