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E:
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Is Stress Hurting You? Diagnostic
Contact Us
Is Stress Hurting You? Diagnostic
Stress Survey
Purpose:
To determine if any health problems you may be having are due to stress.
First Name
Last Name
Email
*
Home Phone
Work Phone
Occupation
# Hours per week of work
# Hours per week of work
Spouse's Occupation
# Hours per week of work
1. Select any symptoms you have experienced in the past 6 months.
Headaches /Tension
Fatigue/Tired
Pain(anywhere in the 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
Numbness/Tingling in Arms or Hands
Numbness/Tingling in Legs or Feet
Weight Trouble
Other
Which of the above bothers you the most?
Please Select One ...
Headaches/Tension
Fatigue/Tired
Pain (anywhere)
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
Numbness/Tingling in Arms or Hands
Numbness/Tingling in Legs or Feet
Weight Trouble
Other
How long have you been bothered by this condition?
Describe how it feels or effects you at its worst?
2. Does this cause you to be:
Moody
Irritable
Sleeping with Interruptions
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, your organs are probably not functioning as well as they could, and your energy is probably not flowing as smoothly as it could be.
ACUPUNCTURE AND CHINESE HERBAL MEDICINE CAN HELP YOU because they gently and naturally treat the body and remove the stress and imbalance that CAUSE health problems.
WOULD YOU LIKE TO GET RID OF THE PROBLEM?
*
YES
NO
If your answer if YES, there are several alternatives available to you. Please check the most appropriate next step for you:
I would like to come to the wellness center for a FREE initial evaluation and consultation.
I would like to attend a wellness class/workshop.
I would like someone to call me to discuss my health problem before making an appointment.
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