Stress Test

examsPURPOSE:

 To determine if you have any stress related problems.

 Your information will be kept strictly confidential.

 When done filling out the form, please click on the "Submit" button.








* Name:
Street Address:
City:
State:
Zip:
Phone:
Age:
Check any of the following symptoms you have experienced in the last 6 months:
Headaches/Migraines
Fatigue
Bladder Trouble
Pain/Tension/Numbness
Constipation
Shoulder/Arm Pain
Hand Pain
Bloating
Menstrual Problems
Irritability
Ringing in Ears
Digestive Trouble
Diarrhea
Lower Back Pain
Gas
Insomnia/Sleep Problems
Asthma
Nervousness
Weight Trouble
Dizziness
Leg Pain
Other:
Which of the above bothers you the most?
How long has this condition persisted?
Describe the feeling/effect when at its worst:
Does this cause you to be:
Moody
Irritable
Interrupt Sleep
Restricted on Daily Activities
Does this affect your work:
Decision Making
Poor Attitude
Decreased Productivity
Exhausted at End of Day
Unable to Work Long Hours
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 or Other Desired Activities


If you checked any of the above items, then you could be suffering from:

EXCESSIVE STRESS, STRUCTURAL MISALIGNMENT, OR PINCHED NERVES

CHIROPRACTIC CAN HELP YOU because Chiropractic Doctors gently treat the body, naturally, without drugs to remove the stress and imbalances that CAUSE health problems.

There are several alternatives available to you. Please check the item most appropriate for you:
I would like to come to the Doctor's office for a complete evaluation. This will allow me to find out if I can helped by Chiropractic without any financial barriers.
I would like the Doctor to call me to discuss my health problems before making an appointment.
I am a member of an HMO or Health Care Network.
Name of HMO (if applicable):
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