Non-Surgical Spinal Decompression
Lower Back Pain

PURPOSE:
This is your self assessment to determine if any health problems you may be having are due to stress.

Please take a minute to fill out this stress survey. After you complete the survey, print it and contact us to schedule an appointment. Don't forget to bring the New Patient Special with you to your appointment!
STRESS SURVEY
Name:
Age:
Phone(H):
Phone(W):
Address:
City:
State:
Zip Code:
Occupation:
# Hours per week currently working:
Spouse's occupation:
# Hours per week currently working:
Email Address:
    
1. Check off any of the following symptoms you have experienced in the past 6 months:
Headaches/Migraines Insomnia/Sleep Problems Menstrual Problems Weight Trouble
Fatigue Irritability Asthma Dizziness
Allergy Problems/Sinus Ringing in Ears Nervousness Other:
Pain/Tension/Numbness: Digestive Trouble: Bladder Trouble
Neck Legs
Shoulders Arms
Low Back Hands
Constipation Diarrhea
Bloating Gas
   
 		  
Which of the above bothers you the 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:
Moody Irritable Interrupt Sleep Restricted on Daily Activities
3. Does this affect your work:
Decision Making Poor Attitude Decreased Productivity
Exhausted at End of Day Unable to Work Long Hours  
4. Does this affect your life:
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, THEN YOU HAVE A HEALTH PROBLEM
YOU SHOULD DO SOMETHING ABOUT IT!


Your symptoms may seem mild or severe. Take action now to see if you still are a candidate for safe, natural chiropractic care to restore you to 100% of your potential. Seek a chiropractor in your area.

To contact us CLICK HERE.

Providing Alternative Healthcare and Chiropractic Services in the following areas:
San Jose, Almaden Valley, Campbell, Los Gatos,
Morgan Hill, Santa Clara County, Saratoga
Non-Surgical Spinal Decompression | Low Back Pain | Privacy Statement

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