Health & Stress Survey

PURPOSE: To 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.

First, tell us a few things about yourself

Name (required):

Age:

Home Phone:

Work Phone:

Address:

City:

State:

Zip Code:

Your Occupation:

Hours per week currently working:

Spouse's occupation:

Hours per week currently working:

Your Email Address (required):

1. Check off any of the following symptoms you have experienced in the past 6 months:

 Headaches / Tension Low Back Pain Pain Between Shoulder Blades Allergies Weight Trouble Fatigue/Tired Neck Pain Knee Pain Shoulder Tension Pain Anywhere in the body Wrist/Hand Pain Ankle/Foot Pain Numbing in Arms Digestive Disturbance Elbow Pain Ringing in Ears Numbing in Legs Insomnia/Sleep Problems Shoulder Pain Nervousness Irritability Hip Pain

Other:

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 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 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 Acupuncturist’s office 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 Chinese herbal Medicine without any finical barriers. I would like to come wellness classes offered at Advanced Healthcare Solutions. I would like more information sent to me in the mail.