The purpose of this stress
survey is to determine if any health problems you may be
having are due to stress. *
indicates required information.
By completing this survey, you qualify to receive a new
patient information packet
1) Check off any of the following symptoms you have
experienced in the past 6 months:
Headache/Tension
Fatigue/Tired
Pain Anywhere in Body
Digestive Disturbance
Difficulty Sleeping
Irritability
Low Back Pain
Neck Pain
Wrist/Hand Pain
Elbow Pain
Shoulder Pain
Hip Pain
Pain Between Shoulder Blades
Knee Pain
Ankle/Foot Pain
Ringing in Ears
Nervousness
Dizziness
Allergies
Tension Across Top of Shoulders
Numbing/Tingling in Arms or Hands
Numbing/Tingling in Legs or Feet
Weight Trouble
Other
Which of the above bothers you the most?
How long have you been bothered by this 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 Sports
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 ·
We Can Help You because we gently treat your body,
naturally, without drugs to remove the stress and imbalances
that Cause health problems.
Would you like to get rid of the problem?
Yes
No
If your answer is Yes, there are alternatives available
to you. Please check the item most appropriate for you.
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