Take our Stress Survey :: Burleson Chiropractic Center :: Chiropractors Providing Chiropractic care in Burleson, Texas

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 examination. Don't forget to bring the Introductory Special with you to your examination!

.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 Sport

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

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