1. Have you ever been diagnosed with diabetes?
   

   Yes
   No
   

2.  Are your feet cold, blue, swollen, or have you ever been told you have a   circulation problem?
   
   

   Yes
   No
   

3.  Do you have feelings of electrical shock, or bugs crawling on your legs?  Do you have numb feet or legs?
   
   

   Yes
   No

4.  Do you have bumps on the sides of your big or little toes?
   
   

   Yes
   No

5.  Do you have heel or arch pain for the first thing in the morning or after you have been resting?
   
   

   Yes
   No

6.  Do you have thick, black, yellow, crumbly, or ugly nails?
   
   

   Yes
   No

7.  Do you have pain in the balls of your feet?
   
   

   Yes
   No

8.  Do you have calloused, scaly, or cracked feet?
   
   

   Yes
   No

9.  Do you get ingrown toenails?
   
   

   Yes
   No

10.  Do you have sores on you feet that are slow healing?
    
    

    Yes
    No

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