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 My Stress Survey!" button at the bottom of the form when done:
STRESS SURVEY
Name:
Age:
Phone(H):
Phone(W):
Address:
City:
State:
Zip Code:
Occupation:
# Hours per week currently working:
Spouse's occupation:
# Hours per week currently working:
Email Address:
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
Weight Trouble
FatigueTired
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
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 Interrupt 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 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.
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: