Small Fibre Neuropathy Screening List (SFNSL)

  Gender:male   female       Age (in years):  
       

Below are a number of questions about possible complaints. Please check the answer to each question that is applicable to you. Please give an answer to each question, even if you do not have any complaints at the moment. The aim of this questionnaire is to find out how you experience your complaints. There are no correct or incorrect answers. It is important that you are honest.


Part 1
These questions are aimed at finding out how often you experience the following complaints:
 
1. I have painful arms

 

 never          sometimes          fluctuating          often         always
2. I suffer from palpitations
  never          sometimes          fluctuating          often         always
3. I have problems with my bowel movements
 

never          sometimes          fluctuating          often         always
4. I have difficulties with urinating (either in emptying my bladder or being able to hold my water)
  never          sometimes          fluctuating          often         always
5. My food does not seem to go down well
  never          sometimes          fluctuating          often         always
6. I suffer from muscle cramps
  never          sometimes          fluctuating          often         always
7. My feet and/or hands are colder than I am used to
  never          sometimes          fluctuating          often         always
8. I have chest pain
  never          sometimes          fluctuating          often         always


Part 2
These questions are aimed at finding out how serious your complaints are!
 
9. I have the feeling that my food gets stuck in my throat
  not at all         slightly         fluctuating          moderately         seriously
10. At night I throw the bedclothes off my legs
  not at all          slightly        fluctuating          moderately         seriously
11. I have difficulties with urinating (either emptying my bladder or being able to hold my water)
  not at all         slightly         fluctuating          moderately         seriously
12. I have dry eyes
  not at all          slightly        fluctuating          moderately         seriously
13. I have blurred vision
  not at all         slightly         fluctuating          moderately         seriously
14. I feel dizzy when I get up
  not at all          slightly        fluctuating          moderately         seriously
15. I have sudden hot flushes
  not at all         slightly         fluctuating          moderately         seriously
16. My feet and/or hands are colder than I am used to
  not at all          slightly        fluctuating          moderately         seriously
17. I have painful arms
  not at all         slightly         fluctuating          moderately         seriously
18. The skin of my legs is over-sensitive
  not at all          slightly        fluctuating          moderately         seriously
19. I  have a tingling sensation in my hands (pins and needles)
  not at all         slightly         fluctuating          moderately         seriously
20. I have a tingling sensation in my legs (pins and needles)
  not at all          slightly        fluctuating          moderately         seriously
21. I have chest pain
  not at all         slightly         fluctuating          moderately         seriously

When all questions are answered, please press the submit button >>  
 

 

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References:

Hoitsma E, De Vries J, Drent M. The small fiber neuropathy screening list: construction and cross-validation in sarcoidosis. Repir Med 2011;105:95-100. http://www.ncbi.nlm.nih.gov/pubmed/20889323