Stress Survey

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:

STRESS SURVEY

Name:		Age:		Phone(H):		Phone(W):
Address:		City:		State:		Zip Code:

Occupation:		# Hours per week currently working:
Spouse's occupation:		# Hours per week currently working:
Email Address:

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
Headaches/Tension	Low Back Pain	Pain Between Shoulder Blades	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	Other:
Irritability	Hip Pain	Dizziness

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 Sport

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, CHINESE HERBAL MEDICINE, CLINICAL NUTRITION and HOMEOPATHIC MEDICINE CAN HELP YOU because they 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 Holistic practice of Jonathan Breslow for an initial evaluation and consultation. This will allow me to find out if I can be helped. To ease financial barriers, there is a gift certificate that enables you to receive this evaluation/consultation for $20, which usually costs $150.00. Click here to receive your gift certificate.
	I would like to come for further wellness classes
	I would like the acupuncturist to call me to discuss my health problem before making an appointment.

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