Stress Survey

The purpose of this survey is to determine whether any health problems you may be having are due to stress.

Name:		Home Phone:
Age:		Work Phone:
Address:		City, State, Zip:
Occupation:		# Hours per week currently working:
Spouse Occupation:		# Hours per week currently working:

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
	Fatigue, Tired			Neck Pain			Knee Pain			Tension Across Top of Shoulders
	Pain Anywhere in Body			Wrist/Hand Pain			Ankle, Foot Pain			Numbing/Tingling in Arms or Hands
	Digestive Disturbance			Elbow Pain			Ringing in Ears			Numbing/Tingling in Legs or Feet
	Difficulty Breathing			Shoulder Pain			Nervous			Weight Trouble
	Irritability			Hip Pain			Dizziness			Other (list below)

Which of the above bothers you 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 ...?			3. Does this affect your work?			4. Does this affect your life?
	Moody			Decision Making			Lose Patience with Spouse or Children
	Irritable			Poor Attitude			Restricted Household Duties
	Interrupt Sleep			Decreased Productivity			Hinders Ability to Exercise or Participate in Sports
	Restricted on Daily Activities			Exhausted at End of Day			Interferes with Ability to Participate in Hobbies
				Unable to Work Long Hours			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 CINESE HERBAL MEDICINE CAN HELP YOU because they gently and 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 most appropriate for you:

	I would like to come to Dr. Tad's office for an initial evaluation and consultation. There is NO CHARGE for this visit. This will allow me to find out if I can be helped by Acupuncture and Chinese Herbal Medicine without any financial barriers.
	I would like to come for further wellness classes.
	Please call me with more information about wellness classes or to schedule a free consultation.