Stress Survey

Name

Age

Phone(H)

Phone(W)

Address

Street AddressAddress Line 2CityState / Province / RegionZip / Postal Code

Occupation

# Hours per week currently working

Email Address

1. Check off any of the following symptoms you have experienced in the past 6 months:

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
Interrupt Sleep
Restricted on Daily Activities

3. Does this affect your work:

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

Would you like to get rid of the problem?

Yes
No

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 to see if acupuncture can help me.
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.

Stress Survey

Call: (828) 265-8668