Small Fiber Neuropathy Inventory Questionnaire (SFN-SIQ)
(to be completed by a subject under supervision of a trained clinician)

DATE: TIME (24hr):


INSTRUCTIONS: Below is a list of problems and complaints that people sometimes have in response to stressful experiences. Please read each one carefully, then click the circle to indicate how much you have been bothered by that problem in the past month. (Never, Sometimes, Often, Always present)

Do you have any of the following: Never Sometimes Often Always
0 1 2 3 4 5 6 7 8 9 10
1. Sweatting
2. Diarrhea
3. Constipation
4. Difficulty starting urination
5. Dry eyes
6. Dry mouth
7. Dizziness when standing up
8. Heart palpitation
9. Hot flashes
10. Skin on legs sensitive to touch
11. Feet have burning sensation
12. Sheets in bed uncomfortable touching feet
13. Restless legs (need to move for discomfort)


TEXT FOR YOUR RECORDS

PCL5 maximum score = 80

0 - 19 normal
20 - 39 mild
40 - 59 moderate
60 - 69 severe
70 - 80 extreme

DATA FILE

PCL-5 for DSM-V (8/14/2013)
Weathers, Litz, Keane, Palmieri, Marx, & Schnurr - National Center for PTSD

Site constructed and maintained by: J. Wesson Ashford, M.D., Ph.D.
Electronic mail address: washford@medafile.com
Forms and papers provided on this site may be copyright protected by their authors or publishers.
HTML code copyright by J. Wesson Ashford, M.D., Ph.D., to retain rights for use.
Dr. Ashford is licensed to practice medicine in the states of California and Kentucky.
Last update: 07/12/2015