Fitness Survey

Please fill out the following information and click the "Submit My Stress Survey!" button at the bottom of the form when done:

Name:

Address:

City:

State:

Zip Code

Phone(H):

Phone(W):

Email Address:

Age:

Occupation:

Spouse's occupation:

How many hours per week do you work?

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

Headaches/Migraines	Weight Trouble	Menstrual Problems
Fatigue	Irritability	Insomnia/Sleep Problems
Bladder Trouble	Ringing in Ears	Dizziness
Pain/Tension/Numbness in:	Digestive Trouble, such as:	Other:
Neck	Constipation
Shoulders	Bloating
Low Back	Gas
Legs	Diarrhea
Arms	Nervousness
Hands	Asthma

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 Sport

Interferes with Ability to Participate in Hobbies or Other Desired Activities

If you checked any of the above items, then you could be suffering from:

EXCESSIVE STRESS

STRUCTURAL MISALIGNMENT

PINCHED NERVES

CHIROPRACTIC CAN HELP YOU because Chiropractic Doctors gently treat the body, naturally, without drugs to remove the stress and imbalances that CAUSE health problems.

If you could eliminate one of the above which would it be?

If your answer is Yes, there are several alternatives available to you. Please check the item most appropriate for you:

	I would like to come to the Doctor's office for a complete evaluation. This will allow me to find out if I can be helped by Chiropractic without any financial barriers.
	I would like the Doctor to call me to discuss my health problems before making an appointment.

Are you a member of an HMO or Health Care Network? Yes No

Name of HMO (if applicable):