STRESS SURVEY -

This survey will determine if any health problems you may be having are due to stress.

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* 1. Check off any of the following symptoms you have experienced in the past 6 months. Mark "Y" for yes, and leave a comment if necessary. A blank response will reflect "No Issues with this item"

Low back pain

Pain between shoulders and blades

Difficulty Sleeping

Tension/Migraine Headaches

Tired/Fatigued

Tension across the top of shoulders

Numbness/Tingling in arms or hands

Numbness/Tingling in legs or feet

Digestive Problems

Ringing in ears

Nervous

Neck Pain

Allergies

Dizziness

Weight Loss

Weight Gain

Other, Please comment:

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* 2. Which of the above is worst?

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* 3. How long have you experienced this?

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* 4. When is it at its worst and how does it feel?

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* 5. Does this cause any of the following? Y or N

Moodiness

Irritability

Interrupted Sleep

Restrictions on Daily Activities

Other?

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* 6. Does this affect your work? Y or N

Decision Making

Poor attitude

Decreased productivity

Exhaustion

Unable to work long hours

Other?

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* 7. Does this affect your life? Y or N

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

Other?

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* 8. 8. Please leave your name and email. We will not share your information with others. We may add your email to our monthly newsletter. You will have the option to opt-out if you do not wish to receive it.

First Name

Last Name