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Take the Stress Test

* Name:
* Age
Phone:
Street Address:
City:
* Email
* Occupation
# Hours per week currently working
Spouse Occupation

By completing this survey, you qualify to receive a new patient information packet

1)

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

Headache/Tension
Fatigue/Tired
Pain Anywhere in Body
Digestive Disturbance
Difficulty Sleeping
Irritability
Low Back Pain
Neck Pain
Wrist/Hand Pain
Elbow Pain
Shoulder Pain
Hip Pain
Pain Between Shoulders
Knee Pain
Ankle/Foot Pain
Ringing in Ears
Nervousness
Dizziness
Allergies
Tension Across Top of Shoulders
Numbing/Tingling in Arms or Hands
Numbing/Tingling in Legs or Feet
Weight Trouble
Which of the above bothers you the most?
How long have you been bothered by this 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 could be suffering from:

Excessive Stress
Structural Misalignment
Pinched Nerves

We Can Help You because we gently treat your body, naturally, without drugs to remove the stress and imbalances that Cause health problems.

Would you like to get rid of the problem?
Yes
No
If your answer is Yes, there are alternatives available to you. Please check the item most appropriate for you.
I would like to come to Lee Chiropractic Clinic and Physical Therapy for a complete evaluation. Please call me to schedule an appointment.
I would like to come to a class on Stress and Wellness.
I would like Lee Chiropractic Clinic and Physical Therapy to call me to discuss my health problems before making an appointment.
I am interested in receiving more information from Lee Chiropractic Clinic and Physical Therapy.