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Form Approved 
OMB No. 0920‐xxxx 
Exp. Date xx/xx/xxxx 

Patient ID
Number

Site

Sub-site

Sequential ID

Patient Version
MICHIGAN NEUROPATHY SCREENING INSTRUMENT
and 10-gram Filament Exam
A. Neuropathic 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.
1.

Are your legs and/or feet numb?

1

No

2

Yes

2.

Do you ever have any burning pain in your legs and/or feet?

1

No

2

Yes

3.

Are your feet too sensitive to touch?

1

No

2

Yes

4.

Do you get muscle cramps in your legs and/or feet?

1

No

2

Yes

5.

Do you ever have any prickling feelings in your legs or feet?

1

No

2

Yes

6.

Does it hurt when the bed covers touch your skin?

1

No

2

Yes

7.

When you get into the tub or shower, are you able to tell the
hot water from the cold water?

1

No

2

Yes

8.

Have you ever had an open sore on your foot?

1

No

2

Yes

9.

Has your doctor ever told you that you have diabetic neuropathy?

1

No

2

Yes

10. Do you feel weak all over most of the time?

1

No

2

Yes

11. Are your symptoms worse at night?

1

No

2

Yes

12. Do your legs hurt when you walk?

1

No

2

Yes

13. Are you able to sense your feet when you walk?

1

No

2

Yes

14. Is the skin on your feet so dry that it cracks open?

1

No

2

Yes

15. Have you ever had an amputation?

1

No

2

Yes

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing 
instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of 
information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a 
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, 
including suggestions for reducing this burden to CDC Reports Clearance Officer; 1600 Clifton Road NE, MS D‐74, Atlanta, Georgia 30333; ATTN: 
PRA (0920‐xxxx) 
SEARCH 3 Michigan Neuropathy Screening Instrument Form - Revised 12 30 2010

Page 1 of 3

NEUROPATHY SCREENING INSTRUMENT
B. Physical Assessment (To be completed by the study personnel)
1.

Appearance of Feet
Right Foot
a. Normal
1
No 2 Yes
b. If no, check all that apply:

Left Foot
Normal 1 No 2 Yes
If no, check all that apply:

Deformities
Dry skin, callus
Infection

Deformities
Dry skin, callus
Infection

1
1
1

Fissure
Other
specify:

1
1
1

Fissure
Other
specify:

1
1

1
1

Right Foot
2.

3.

Ulceration
Present

Absent

Present

1

2

1

2

Present/
Reinforcement Absent

1

2

Present

3

1

Absent

Present

3

1

Present/
Reinforcement Absent
2

3

Vibration perception at the great toe*
Present

Reduced

1

5.

Absent
Ankle Reflexes
Present

4.

Left Foot

2

Reduced
2

Absent
3

10 gm filament (number of applications detected out of 10 applications):
Present (≥ 8)
1

Reduced (1-7)
2

Absent( 0)
3

Present (≥ 8)
1

Reduced (1-7)

Absent( 0)

2

3

*Vibration is Present if the examiner feels vibration on his finger joint for 10 seconds or less after the patient reports vibration
at toe has stopped. Vibration is Reduced if examiner feels vibration for more than 10 seconds after patient reports vibration at
toe has stopped. Vibration is Absent if patient does not perceive any vibration from the tuning fork.

SEARCH 3 Michigan Neuropathy Screening Instrument Form - Revised 12 30 2010

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FOR STUDY USE ONLY
Date
Completed
Date
Reviewed
Date
Entered

Month

Month

Month

Day

Day

Day

Year

Year

Year

SEARCH 3 Michigan Neuropathy Screening Instrument Form - Revised 12 30 2010

Completed
by
Reviewer
Code
Data Entry
Code

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