STRESS SURVEY
Name:
 Age:
 Zip Code:
 E-mail:
1. Check off any of the following that apply to you indicating the total of occurensies in your lifetime:
Accidents:
 Surgeries:
 Diagnosed illnesses:
2. Check off any of the following symptoms you have experienced in the past 6 months:
Headaches/Tension

Fatigue/Tired

Pain anywhere in The
                       Body
Digestive Disturbance

Insomnia/Sleep    
Problems
Irritability
 Low Back Pain

Neck Pain/Tightness

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:
3. Does this cause you to be:
Moody
 Irritable
 Interrupt Sleep
 Restricted on Daily Activities
4. Does this affect your work:
Poor Attitude
Decreased Productivity
Decision Making
Unable to work long hours
Exhausted at End of Day
5. 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
6. Would you like to get rid of the problem?
No
Yes
CONTINUE->>
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2003 © New York Medical Acupuncture. All rights reserved.


SURVEY YOURSELF

There are three major Stress Factors: physical, chemical, and
emotional.
The purpose of this survey is 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 "Continue"   
at the bottom of the form when done:
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