STRESS FORM

Stress Form

Name
First Last
Age
Phone (Home)*
Phone (Work)
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation
Number of Hours Currently Working Per Week
Spouse Occupation
Number of Hours Souse Currently Working per Week
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
- Difficulty Breathing
- Irritiability
- Low Back Pain
- Neck Pain
- Wrist/Hand Pain
- Elbow Pain
- Shoulder Pain
- Hip Pain
- Knee Pain
- Ankle Foot Pain
- Ringing in Ears
- Nervous
- Dizziness
- Weight Trouble
- Tension Across Shoulders
- Numbing/Tingling in Arms or Hands
- Numbing/Tingling in Legs or Feet
- Pain Between Shoulder Blades
Other Symptom
Which of the above bothers you most?
How long have you had the condition?
Describe how it affects you at its worst:
This causes me to be:
- Moody
- Irritiable
- Interrupted Sleep
- Restricted on Daily Activities
At work this leads to:
- Decisions Making Problems
- Poor Attitude
- Decreased Productivity
- Exhaustion at the End of the Day
- Inability to Work Long Hours
This also affects:
- Patience with Spouse or Children
- My Household Duties
- My Ability to Exercise or Participate in Sports
- My Ability to Participate in Hobbies or Other Desired Activities
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 the Acupuncturist’s office for a Chinese Medical Exam and initial Consultation. The visit is $75 pre-paid and you will receive dietary and herbal recommendations.
- I would like to come for further wellness classes.
- Call me to discuss health problems before scheduling an appointment.

If you check 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 CHINESE HERBAL MEDICINE CAN HELP YOU because they gently and naturally treat the body to remove the stress and imbalance that CAUSE health problems.

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Chesterton

(219) 395-9928
210 N. Calumet Road