Take The
Stress Test
The purpose of this stress survey is to determine if any
health problems you may be having are due to stress. *
indicates required information.
By completing this survey,
you qualify to receive a new patient information packet
1) Check off any of the
following symptoms you have experienced in the past 6 months:
Headache/Tension
Fatigue/Tired
Pain Anywhere in 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
Nervous
Dizziness
Allergies
Tension Across Top of Shoulders
Numbing/Tingling in Arms or Hands
Numbing/Tingling in Legs or Feet
Weight Trouble
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.
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, then you could be suffering from:
·
Excessive Stress ·
· Structural Misalignment ·
· Pinched Nerves ·
We Can Help You because we gently treat 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 Trice Chiropractic Clinic for a complete evaluation.
Please call me to schedule an appointment.
I would like to come to a class on Stress and Wellness.
I would like Trice Chiropractic Clinic to call me to discuss my health problems
before making an appointment.
I am interested in receiving more information from Trice Chiropractic Clinic.
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