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Is Stress Hurting You? Diagnostic

Stress Survey

Purpose: To determine if any health problems you may be having are due to stress.

1. Select any symptoms you have experienced in the past 6 months.
Headaches /TensionFatigue/TiredPain(anywhere in the body)Digestive DisturbanceDifficulty SleepingIrritability
Low Back PainNeck PainWrist/Hand PainElbow PainShoulder PainHip Pain
Pain Between Shoulder BladesKnee PainAnkle/Foot PainRinging in EarsNervousnessDizziness
AllergiesTension Across Top of ShouldersNumbness/Tingling in Arms or HandsNumbness/Tingling in Legs or FeetWeight TroubleOther

Which of the above bothers you the most?

2. Does this cause you to be:

MoodyIrritableSleeping with InterruptionsRestricted on Daily Activities

3. Does this affect your work:

Decision MakingPoor AttitudeDecreased ProductivityExhausted at End of DayUnable to Work Long Hours

4. Does this affect your life:

Lose Patience with Spouse or ChildrenRestricted Household DutiesHinders Ability to Exercise or Participate in SportsInterferes with Ability to Participate in Hobbies 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 CHINESE HERBAL MEDICINE CAN HELP YOU because they gently and naturally treat the body and remove the stress and imbalance that CAUSE health problems.


WOULD YOU LIKE TO GET RID OF THE PROBLEM?

YESNO


If your answer if YES, there are several alternatives available to you. Please check the most appropriate next step for you:

I would like to come to the wellness center for a FREE initial evaluation and consultation.I would like to attend a wellness class/workshop.I would like someone to call me to discuss my health problem before making an appointment.

 

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