Stress Survey

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

First Name:		Last Name:
Age:	Home Phone:	Work Phone:
Occupation:		# Hours per week of work:
Spouse's Occupation:		# Hours per week of work:

1. Select any 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 the body)	Wrist/Hand Pain	Ankle/Foot Pain	Numbness/Tingling in Arms or Hands
Digestive Disturbance	Elbow Pain	Ringing in Ears	Numbness/Tingling in Legs or Feet
Difficulty Sleeping	Shoulder Pain	Nervousness	Weight Trouble
Irritability	Hip Pain	Dizziness	Other

Which of the above bothers you the most?
How long have you been bothered by this condition?
Describe how it feels or effects you at its worst?

2. Does this cause you to be:

3. Does this affect your work:

4. Does this affect your life:

	Moody
	Irritable
	Sleeping with Interruptions
	Restricted on Daily Activities

	Decision Making
	Poor Attitude
	Decreased Productivity
	Exhausted at End of Day
	Unable to Work Long Hours

	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, 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? YES NO

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.

DIRECTIONS
3547 Camino Del Rio South, Ste. C, San Diego, CA 92108
619-287-4005 | fax: 619-287-1135 | drmancini@manciniacupuncture.com