pdf patient assessment/ - HFX Australia

Have you previously been diagnosed with diabetes?

Yes

HFX includes a Senza spinal cord stimulation system that uses 10 kHz Therapy to treat pain from diabetic neuropathy.

What type of diabetes do you have?

Type 1

Type 2

Not applicable

How long have you experienced painful diabetic neuropathy?

Less than 1 year

1-3 years

4-10 years

More than 10 years

I don't experience pain

On an average day, how would you rate the pain related to your diabetic neuropathy?

No Pain

Worst Pain Imaginable

No Pain

Worst Pain Imaginable

Over the past six months, how often does your painful diabetic neuropathy limit your life or work activities?

Never

Some days

Most days

Every day

Where is your painful diabetic neuropathy located?

(Select all that apply)

Foot/Feet

Leg(s)

Arm(s)/Hand(s)

Other

Please select one or more answers Next

Which of the following treatments have you tried to help manage your painful diabetic neuropathy symptoms?

(Select all that apply, past and current)

Prescription medication(s)

Topical treatments

Physical therapy

TENS Unit

Chiropractic care

None of the above

Please select one or more answers

Which health care professional is currently helping to manage your pain?

General practitioner (GP) or primary care physician (PCP)

Endocrinologist

Diabetes nurse educator

Podiatrist

Neurologist

Pain specialist

Other

None

Are you satisfied with your current treatment?

Yes

Please select your primary type of health insurance:

I have private health insurance

I do not have private health insurance

I have an active workcover (or similar) claim

I have a Department of Veteran Affairs card

Unknown

I answered these questions on behalf of:

Myself A relative or friend

HFX is FDA approved in the United States for the treatment of chronic intractable pain of the trunk and/or limbs. Only a physician can recommend a specific treatment option.

Thank you for sharing your experience.

Unfortunately it's unclear at this time whether you are an appropriate candidate for HFX.

- If you have painful diabetic neuropathy, but are not satisfied with the level of relief from prescription medications, or the side effects are negatively impacting your quality of life, then you may want to talk to your primary care physician about alternative treatment options.

- If have another kind of neuropathy, or chronic nerve pain of the trunk (including back, hip, and pelvis) and limbs, then you may want to visit NevroHFX.com to learn about how HFX can help those pain conditions.

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Your pain condition appears similar to other patients being treated with HFX^TM for PDN.

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