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PN

Exploration of Clinical Characteristics and Treatment Patterns in Painful Neuropathy among Indian Patients: A Cross-Sectional Study

Patient No *

Patient Initials *

Demographic Information

Age (in Years) *

Gender *

Male Female

Medical History

Primary Diagnosis *

Past Medical History *

Allergies *

Current Medications *

Clinical Assessment

Neuropathy Diagnosis (Type of Neuropathy)*

Date of Diagnosis *

Symptom Onset *

Symptom Characteristics (Description of Pain (e.g., burning, shooting))*

Distribution of Symptoms *

Pain Severity *

Mild Moderate Severe

Sensory Abnormalities (Numbness, Tingling)*

Motor Symptoms (Weakness, Muscle Atrophy)*

Laboratory Investigations (If Available)

Vitamin D Level

Glycemic Parameters

Hemoglobin A1c

Other Relevant Biomarkers

Treatment History

Current Treatment *

Medication Non-pharmacological Any other

Medication Name*

Dosage*

Frequency*

Route of Administration : (Oral, Topical, etc)*

Duration*

Impact on Daily Activities*

Quality of Life*

SF-36 Score

The following questions are about activities you might do during a typical day. In the past 1-week does your health limit you in these activities? If so, how much?

(Please circle one number on each line)

ACTIVITIES	Yes Limited A lot	Yes Limited A little	No, Not Limited At All
3a: Vigorous activities, such as running, lifting heavy Objects, participating in strenuous sports
3b: Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
3c: Lifting or carrying groceries
3d: Climbing several flights of stairs
3e: Climbing one flight of stairs
3f: Bending, kneeling, or stooping
3g: Walking more than one kilometre
3h: Walking half a kilometre
3i: Walking 100 metres
3g ww: Wheeling more than one kilometre
3h ww: Wheeling half a kilometre
3i ww: Wheeling 100 metres
3j: Bathing or dressing yourself
"Modified from SF-36': Items 3 (a to j) are the original SF-36 questions, while 3g ww to 3i ww (shaded area) comprise the supplementary SF-36ww modification.