The
PURPOSE of this form will help:
Determine if any health problems you may be
having are due to stress. All information is
kept in strict confidence and we never share or
give out your information.
Please fill out the following information and
click the "Submit My Stress Survey!" button at
the bottom of the form when done:
Stress is one of the most treatable (without
drugs) causes of many ailments.
Evaluation Form
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 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 Doctor's office for a
complete evaluation. This will allow me to find out
if I can be helped by Chiropractic without any
financial barriers.
I would like the Doctor to call me to discuss my
health problems before making an appointment.
Are
you a member of an HMO or Health Care Network?
Yes
No
Name
of HMO (if applicable):
This test prevents automated submissions
Enter the text that appears in above image:
website design & contents copyright 2006, 2007, 2008 all right reserved
