STRESS SURVEY

To determine if any of your health problems are due to stress.
All information is held in strict confidence.
 

(optional information section)

Name Age

Address

City State Zip

Telephone  DAY   EVENING

Email

Occupation No. of Hours a week currently working:

Married/Partnership yes no

Spouse's
Occupation No. of Hours a week currently working:

 

1. Check off any of the following symptoms you have experienced in the past six months:

Headaches/Tension  Low Back Pain Pain Between Shoulder
      Blades 		Allergies
Fatigue/Tired Neck Pain Knee Pain Tension Across Top
      of Shoulders
Pain Anywhere in Body Wrist/Hand Pain Ankle/Foot Pain Numbing/Tingling in
      Arms or Hands
Digestive Disturbance Elbow Pain Ringing in Ears Numbing/Tingling in
      Legs or Feet
Difficulty Sleeping Shoulder Pain Nervous   Weight Trouble
Irritability Hip Pain Dizziness Other:

Which of the above bothers you the most?   

How long have you been bothered by this condition? 

Describe how it feels or effects you when it is at its worst:
               

2. Does this cause you to be:

Moody Irritable Sleeping with Interruptions Restricted 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, Sports or Other Activities

 

If you checked more then 1 box in sections 2,3, or 4 then Stress is lowering your quality of life.


WOULD YOU LIKE TO GET RID OF THE PROBLEM? YES NO

If you answered yes, there are several alternatives available to you. Please check the most appropriate for you.

 

I would like to come to the Orlando Acupuncture office for an initial evaluation and consultation.

There is NO CHARGE for this visit. This would allow me to find out if I can be helped by Acupuncture and Oriental Medicine without any financial barriers.

 

I would like one of the Aupuncture Physicians call me to discuss my health problems before making an appointment.

 

Please be sure to fill out the optional information section above when making a selection.

1890 State Rd. 436 (Semoran), Winter Park, FL

(407) 673-6700