Stress Survey

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Stress Survey

Fill out the following survey to determine if physical stress is playing too large of a role in your life.

Check off all of the following symptoms you've experienced in the last 6 months: Low Back Pain: Pain Between Shoulders: Neck Pain: Tension or Headaches: Tired or Fatigued: Wrist or Hand Pain: Elbow Pain: Shoulder Pain: Hip Pain: Knee Pain: Ankle or Foot Pain: Ringing in Ears: Tension Across Top of Shoulder: Numbing or Tingling in Arms: Numbing or Tingling in Hands: Numbing or Tingling in Legs: Numbing or Tingling in Feet: Dizziness: Nervous: Difficulty Sleeping: Allergies: Digestive Problems:

Which above is the worst:

How long have you had it:

How does it feel at worst:

Which of the following have you experienced that affect your everyday life? Moody: Irritable: Interrupted in Sleep: Restricted on Daily Activities: Decision Making: Poor Attitude: Decreased Productivity: Exhausted at End of Day: Unable to Work Long Hours: Lose Patience: Restricted in Home Activities: Hinders Ability to Exercise: Hinders Desired Activities:

Would you like to be relieved of your pain or discomfort and correct your problem as much as possible?

Fill out the information below and click 'Submit Form' to email your survey to Dr. Harstad. Your results will be evaluated and Dr. Harstad will contact you through email or by phone if desired, to set up a complete evaluation at no charge and discuss how Chiropractic care can help you.

Name:

Age:

Occupation:

Hours per week working:

Email address:

Phone Number:*