Spine & Sports Chiropractic 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 Stress Survey!" button at the bottom of the form when done
Please fill in the contact information below before you take the survey
Which symptoms have you had in the last 6 months? (Check all that apply.)
Headaches Migraines
Insomnia Sleep Problems
Menstrual Problems
Weigh Trouble
Fatigue
Irritability
Asthma
Dizziness
Bladder Trouble
Ringing in Ears
Nervousness
Other
Pain Tension Numbness
Digestive Trouble
Neck
Shoulders
Low Back
Constipation
Bloating
Legs
Arms
Hands
Diarrhea
Gas
Which of the above bothers you the most ?
How long have you been bothered by this condition?
AFFECTS
How does this cause you to feel? (check all that apply)
Moody
Irritable
Interrupted Sleep
Restricted on Daily Activities
How this affects your work. (check all that apply)
Decision Making
Poor Attitude
Exhausted at End of Day
Decreased Productivity
Unable to Work Long Hours
How this affects your life. (check all that apply)
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 Desired Activities
If you checked any of the above items, then you could be suffering from:
•
EXCESSIVE STRESS
•
STRUCTURAL MISALIGNMENT
•
PINCHED NERVES
CHIROPRACTIC CAN HELP YOU because Chiropractic Doctors gently treat the body, naturally, without drugs, to remove the stress and imbalances that CAUSE health problems.
If you could eliminate one of the above would you
Yes
No
If your answer is Yes, there are several alternatives available to you. Please check the item below most appropriate for you:
SCHEDULE an APPOINTMENT
I would like to schedule an appointment with Spine & Sports Chiropractic office for a complete evaluation.This will allow me to find out if I can be helped by Chiropractic
Yes
No
PHONE CONSULTATION
I would like the Doctor to call me to discuss my health problems before making an appointment.
Yes
No
Comments
Please provide additional comments about your symptoms.
press one time to send