Symptom Survey 1 title

Take the symptom survey and share it with your doctor

This survey is meant to help you have a discussion with your doctor about the symptoms you're experiencing. Be sure to fill out the entire survey so your doctor can determine if your symptoms are related to CIDP.

Symptoms Survey Form

Which of these symptoms have you been experiencing?

Indicate how long you've been experiencing symptoms and how you're feeling.

Symptoms Time: (wks/mos/yrs) Same Better Worse
Numbness, tingling, and pain
a. Numbness
b. Tingling in arms, legs, or face
c. Pain in arms, legs, or face
d. Burning or stabbing pain
Physical functioning
a. Fatigue
b. Weakness in arms
c. Weakness in legs
d. Difficulty lifting objects over your head
e. Difficulty climbing stairs
f. Difficulty walking
g. Difficulty writing, buttoning shirts, or using utensils
h. Problem getting up after a fall
Balance
a. Difficulty walking on uneven surfaces
b. Frequent falls
c. Losing balance in the shower
Numbness, tingling, and pain
Physical functioning
Balance
Where have you been feeling your symptoms?

Click the areas in the human figure where you are currently experiencing symptoms.

Additional details

Is there anything else you'd like to tell your doctor? Please use the open field below.

500 character limit

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