Stress Survey :: Dr. Mark Miller D.C. :: Chiropractic & Sports Injury Services in Oakland and San Leandro, California

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Holistic Acupuncture provides help with stress in Milwaukee, Wisconsin using acupuncture care.

PURPOSE:
To determine if any health problems you may be having are due to pain. All information is kept in strict confidence and we never share or give out your information.Please fill out the following information and click the "Submit My Pain Survey!" button at the bottom of the form when done:

PAIN 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/Tension	Low Back Pain	Pain Between Shoulder Blades	Allergies
Headaches/Tension	Low Back Pain	Pain Between Shoulder Blades	Weight Trouble
FatigueTired	Neck Pain	Knee Pain	Shoulder Tension
Pain Anywhere in the body	Wrist/Hand Pain	Ankle/Foot Pain	Numbing in Arms
Digestive Disturbance	Elbow Pain	Ringing in Ears	Numbing in Legs
Insomnia/Sleep Problems	Shoulder Pain	Nervousness	Other:
Irritability	Hip Pain	Dizziness

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, your organs are probably not functioning as well as they could, and your energy is probably not flowing as smoothly as it could be.

CHIROPRACTIC CAN HELP YOU because they grant and naturally treat the body to remove the stress and imbalance that cause health problems.

Would you like to get rid of the problem? Yes No

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 Dr. Miller’s office for an initial evaluation and consultation. There is NO CHARGE for this visit. This will allow me to find out if I can be helped by Dr. Miller without any financial barriers.
	I would like to come for further wellness classes
	I would like Dr. Miller to call me to discuss my health problem before making an appointment.

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