STRESS SURVEY

Purpose: To determine if any health problems you may be having are due to stress.

Name _________________________________ Age _________ Phone (Home) ______________ (Work) _______________

Address __________________________________ City __________________ State ______ Zip ___________________

Occupation _______________________________ # Hours per week currently working _____________________________

Spouse Occupation _________________________ # Hours per week currently working ______________________________

1. Circle the number of any of the following symptoms you have experienced in the past 6 months:

1. Low Back Pain 8. Shoulder Pain 15. Weight Trouble

2. Neck Pain 9. Hip Pain 16. Tension Across the top of shoulders

3. Pain between shoulder blades 10. Knee Pain 17. Tingling / Numbness in Arms or Hands

4. Headaches 11. Ankle / Foot Pain 18. Tingling / Numbness in Legs or Foot

5. Tired or Fatigued 12. Ringing in the ears 19. Dizziness

6. Wrist / Hand Pain 13. Allergies 20. Nervousness

7. Elbow Pain 14. Digestive Troubles 21. Difficulty Sleeping

Which one of the above symptoms is worst? ____________ How long have you had it? _______________________________

When it is at it’s worst, how does it feel? ____________________________________________________________________

What medications are you taking for it? _____________________________________________________________________

2. Circle how this causes you to act:

1. Moody 2. Irritable 3. Interrupts Sleep 4. Restricts daily activities 5. Other _______________

3. Circle how this bothers you at work:

1. Decision Making 2. Exhausted at End of Day 3. Decreased Productivity 4. Poor Attitude

5. Unable to Work Long Hours 6. Other __________________________________________________________________

4. Circle how this hinders your life:

1. Lose patience with spouse or children 2. Hinders ability to exercise or participate in sports

3. Restricted household duties 4. Interferes with ability to participate in hobbies or other activities

5. Other _______________________________________________________________________________________________

If you circled any of the above items, then you could be suffering from

EXCESSIVE STRESS, STRUCTURAL MISALIGNMENT or PINCHED NERVES

Chiropractic can help you because Chiropractic Doctors treat the body gently, naturally, and without drugs to remove your 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 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. There is NO CHARGE for this examination.

I would like to come to a class on STRESS AND WELLNESS.

I would like the Doctor to call me to discuss my health problems before making an appointment.