Stress Survey

Name: *

E-Mail Address: *

Age

Phone

Address

Occupation

Work Hours per Week

Symptoms

Check any of the following symptoms you have experience in the past 6 months:

Headaches/Tension
Fatigue/Tired
Pain Anywhere in the body
Digestive Distrubance
Insomnia/Sleep Problems
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
Nervousness
Dizziness
Allergies
Weight Trouble
Shoulder Tension
Numbing in Arms
Numbing in Legs
Other

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:

Affects

Does this cause you to be:

Moody
Irritable
Interrupted Sleep
Restricted on Daily Activities

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

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 gently and naturally treat the body to remove the stress and imbalance that cause health problems.

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