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Online Wellness Evaluation

Stress Survey

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

*Required

Contact & General Information:

*First Name:

*Last Name:

*E-mail Address:

Telephone (10 digit): Ext.

Occupation:

# Hours per week currently working:

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

Headaches/Tension
Fatigue/Tired
Pain Anywhere in the Body
Digestive Disturbances
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?

How long have you been bothered by the condition?

Describe how it feels or affects you when it is at its worst.

Does this cause you to be:
Moody
Irritable
Sleeping with Interruptions
Restricted on Daily Activities

Does this affect your work:
Decision Making
Poor Attitude
Decreased Productivity
Exhausted at End of Day
Unable to Work Long Hours

 

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 have any of the above symptoms ACUPUNTURE, CHIROPRACTIC CARE, MASSAGE THERAPY AND HERBAL MEDICINE CAN HELP YOU because they gently 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 alternatives available to you.

Please check the most appropriate for you:

 

 

I would like to come to the Whole Health Center for an initial evaluation and consultation. There is a DISCOUNT available for this visit. This will allow me to find out if I can be helped by Acupuncture and Herbal Medicine.

 

 

I am interested in attending wellness classes offered by Whole Health Center.

By submitting this form you are requesting to be contacted by a staff member at Whole Health Center.



 
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