PURPOSE:
This is your self assessment to determine if any health problems you may be having are due to stress.
Please
take a minute to fill out this stress survey. After
you complete the survey, print it and contact
us to schedule examination. Don't forget to
bring the Introductory
Special with you to your examination!
STRESS
SURVEY
Name:
Age:
Phone(H):
Phone(W):
Address:
City:
State:
Zip
Code:
Occupation:
#
Hours per week currently working:
Spouse's
occupation:
#
Hours per week currently working:
Email
Address:
1.
Check off any of the following symptoms you have
experienced in the past 6 months:
Headaches/Migraines
Insomnia/Sleep Problems
Menstrual Problems
Weight Trouble
Fatigue
Irritability
Asthma
Dizziness
Bladder Trouble
Ringing in Ears
Nervousness
Other:
Pain/Tension/Numbness:
Digestive Trouble:
Neck
Legs
Shoulders
Arms
Low Back
Hands
Constipation
Diarrhea
Bloating
Gas
Which
of the above bothers you the most?
How
long have you been bothered by the condition?
Describe
how it feels or affects you when it is at its worst:
2.
Does this cause you to be:
Moody
Irritable
Interrupt Sleep
Restricted on Daily Activities
3.
Does this affect your work:
Decision Making
Poor Attitude
Decreased Productivity
Exhausted at End of Day
Unable to Work Long Hours
4.
Does this affect your life:
Lose Patience with Spouse or Children
Restricted Household Duties
Hinders Ability to Exercise or Participate
in Sport
Interferes with Ability to Participate in
Hobbies or Other Desired Activities
If
you checked any of the above items, then you could
be suffering from:
•
EXCESSIVE
STRESS
•
STRUCTURAL
MISALIGNMENT
•
PINCHED
NERVES
CHIROPRACTIC
CAN HELP YOU because Chiropractic Doctors
gently treat the body, naturally, without drugs
to remove the stress and imbalances that CAUSE
health problems.
If
you could eliminate one of the above which would
it be?
IF YOU CHECKED ANY OF THE ABOVE ITEMS, THEN YOU HAVE A HEALTH PROBLEM
Your symptoms may seem mild or severe. Chiropractic Care & Acupuncutre
can restore you to 100% of your potential.
