Michigan Neuropathy Screening Instrument form

A. History (to be completed by the person with diabetes)
Please take a few minutes to answer the following questions about the feeling in your legs and feet. Check "Yes" or "No" based on how you usually feel. Thank you.
Are your legs and/or feet numb?				Yes	No
Do you ever have any burning pain in your legs and/or feet?				Yes	No
Are your feet too sensitive to touch?				Yes	No
Do you get muscle cramps in your legs and/or feet?				Yes	No
Do you ever have any prickling feelings in your legs or feet?				Yes	No
Does it hurt when the bed covers touch your skin?				Yes	No
When you get into the tub or shower, are you able to tell the hot water from the cold water?				Yes	No
Have you ever had an open sore on your foot?				Yes	No
Has your doctor ever told you that you have diabetic neuropathy?				Yes	No
Do you feel weak all over most of the time?				Yes	No
Are your symptoms worse at night?				Yes	No
Do your legs hurt when you walk?				Yes	No
Are you able to sense your feet when you walk?				Yes	No
Is the skin on your feet so dry that it cracks open?				Yes	No
Have you ever had an amputation?				Yes	No
				Total score:* __________
B. Physical assessment (to be completed by health professional)
Right			Left
Appearance of foot			Appearance of foot
Normal	Yes 0	No 1	Normal	Yes 0	No 1
If no, check all that apply:			If no, check all that apply:
Deformities			Deformities
Dry skin, callus			Dry skin, callus
Infection			Infection
Fissure			Fissure
Other			Other
Specify: ____________________			Specify: ____________________
Ulceration			Ulceration
Absent 0	Present 1		Absent 0	Present 1
Ankle reflexes			Ankle reflexes
Present 0	Present/reinforcement 0.5	Absent 1	Present 0	Present/reinforcement 0.5	Absent 1
Vibration perception at great toe			Vibration perception at great toe
Present 0	Decreased 0.5	Absent 1	Present 0	Decreased 0.5	Absent 1
Total score: __________ /8 points
Signature: _____________________________________________

* For the history questionnaire (part A), a "no" response to questions 7 and 13 is abnormal and is scored as one point. For all other questions, a "yes" response is abnormal and is scored as one point.

Reproduced with permission from: Michigan Neuropathy Screening Instrument: Patient Version. https://medicine.umich.edu/sites/default/files/downloads/MNSI_patient.pdf (Accessed on May 10, 2023).

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Michigan Neuropathy Screening Instrument form