Stress Survey :: Acupuncture at Lakeview :: Quality Holistic Health Care In Chicago, Illinois

PURPOSE:
To determine if any health problems you may be having are due to stress.

Please fill out the following information and click the "Print My Stress Survey" button at the bottom of the form when done. Please fax it to us at (772) 384 - 2003 so we can better assist you with your stress symptoms.

Stress Survey

Name:		Age:
Phone (H):		Phone (W):
Occupation:		Hour Per Week Currently Working:
Spouse's Occupation:		Hour Per Week Currently Working:
Email:

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
Fatigued/ 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	Weight Trouble
Irritability	Hip Pain	Dizziness	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

Interrupted 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

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 and Chinese herbal Medicine without any finical barriers.
	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.

Print and Fax to (772) 384-2003

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