East Wind Acupuncture - Stess Survey

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

* Required Field

1	Client Information:

*Name:

Please Enter Your Name.Invalid format.

Age:

*Phone (Home):

Please Enter a Phone Number.

Phone (Work):

*Email:

Please Enter a Valid Email

Address:

City:

State:

Zip Code:

Occupation:

Number of Hours currently
working per week:

Spouse Occupation:

Number of Hours currently
working per week:

2	Check off any of the following symptoms you have experienced in the past 6 months:

Headaches/Tension

Fatigue, Tired

Pain Anywhere in Body

Digestive Disturbance

Difficulty Breathing

Irritability

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:

Which of the above bothers you most?

How long have you had the condition?

Describe how affects you at its worst:

3	This causes me to be:

4	At work, this leads to:

5	This also affects:

Moody

Irritable

Interupted Sleep

Restricted on Daily Activities

Decision Making Problems

Poor Attitude

Decreased Productivity

Exhaustion at the End of Day

Inability to Work Long Hours

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

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.

WOULD YOU LIKE TO GET RID OF THE PROBLEM:

Yes

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 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.

Call me to discuss health problems before scheduling an appointment.