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 Participat 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.

Click Here To Print Your Stress Survey!