Please fill out the following information and click the "Submit My Stress Survey!" button at the bottom of the form when done:
STRESS SURVEY
Name:
Age:
Phone:
Email:
Address:
City:
State:
Zip Code:
Occupation:
# Hours per week currently working:
Spouse's occupation:
# Hours per week currently working:
1. Check off any of the following symptoms you have experienced in the past 6 months:
Shoulder Pain
Ankle/Foot Pain
Numbing in Arms
Knee Pain
Headaches/Tension
Numbing in Legs
Wrist/Hand Pain
Nervousness
Shoulder Tension
Elbow Pain
Allergies
Weight Trouble
Irritability
Ringing in Ears
Others
FatigueTired
Pain Anywhere in the body
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, your organs are probably not functioning as well as they could, and your energy is probably not flowing as smoothly as it could be.
CLASSICAL ACUPUNCTURE CAN HELP YOU because they grant and naturally treat the body to remove the stress and imbalance that cause health problems.
Would you like to get rid of the problem?
Yes
No
If your answer is Yes, there are several alternatives available to you. Please check the item most appropriate for you:
I would like to come to the Classical Acupuncture Clinic for an initial evaluation and consultation. There is NO CHARGE for this visit. This will allow me to find out if I can be helped by Acupuncture Medicine without any finical barriers.
I would like to come for further wellness classes
I would like the acupuncturist to call me to discuss my health problem before making an appointment.
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