Stress Survey Provided by American Chiropractic, Providing Chiropractic Care in Louisville, Kentucky (KY)

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 "Print My Stress Survey" button at the bottom of the form when done. Please bring this with you to our office so we can better assist you with your stress symptoms.

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/Migraines

Insomnia/Sleep Problems

Menstrual Problems

Weight Trouble

Fatigue

Irritability

Asthma

Dizziness

Bladder Trouble

Ringing in Ears

Nervousness

Other:

Pain/Tension/Numbness:

Digestive Trouble:

Neck	Legs
Shoulders	Arms
Low Back	Hands

Constipation	Diarrhea
Bloating	Gas

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, then you could be suffering from:

•

EXCESSIVE
STRESS

•

STRUCTURAL
MISALIGNMENT

•

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.

If you could eliminate one of the above which would it be?

Are you a member of an HMO or Health Care Network? Yes No

Name of HMO (if applicable):

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