Stress  Test
     

The purpose of this stress survey is to determine if any health problems you may be having are due to stress.  Please fill out this form online, then print it and bring it to the office on your first visit.  If you wish, you may first print this form, then fill it out later by hand.

This form may be printed by going to the File menu at the top of this screen, then selecting Print.

                                    Name
                                       Age
                          Home Phone
                           Work Phone
                                 Address
                                       City
                                     State
                                Zip Code
                       E-mail Address
                             Occupation
         Hours Worked per Week
              Spouse's Occupation
 Hours per Week Spouse Works


1)
 Please indicate how you found our clinic.:
 

2)
Check off any of the following symptoms you have experienced in the past  six months:
Headache/Tension Pain Between Shoulder Blades
Fatigue/Tired Knee Pain
Pain Anywhere in Body Ankle Foot Pain
Digestive Disturbance Ringing in Ears
Difficulty Sleeping Nervous
Irritability Dizziness
Low Back Pain Allergies
Neck Pain Tension Across Top of Shoulders
Wrist/Hand Pain Numbing/Tingling in Arms or Hands
Elbow Pain Numbing/Tingling in Legs or Feet
Shoulder Pain Weight Trouble
Hip Pain
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.


3)
 How does it affect you::
It makes me moody
It makes me Irritable
Sleep is interrupted
Restricted on Daily Activities

4)
 How does it affect your work:
Decision Making
Poor Attitude
Decreased Productivity
Exhausted at End of Day
Unable to Work Long Hours

4)
 How does it 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
The doctor can help you because he gently treats 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.

I would like to come to our office for a complete evaluation. Please call me to schedule an appointment.
I would like to come to a class on Stress and Wellness.
Please call me to discuss my health problems before making an appointment.

         

              JA February 2005


   

DISCLAIMER: No individuals, including those under our active care, should use the information, resources or tools contained within to self-diagnose or self-treat any health-related condition. Diagnosis and treatment of all health conditions should only be performed by your doctor of chiropractic or other licensed health care professional.