Free Seminars and Education on Acupuncture  
  Health Problems STRESS SURVEY  
  What Health Issues
can Acupuncture Treat?
  Chinese energy hand, abstract meridian points, painted with Chinese characters.  
  Chinese Energy Hand  



Taking our Stress Survey helps us determine if any of the health problems you're experiencing are due to stress.

We respect your privacy. All information is kept in strict confidence and will only be used to assist in improving your health. This information will never be shared or sold.

Please fill out the survey as accurately as possible and Submit when complete.
* = Required

* Name:  Day-Phone: 
Address:  Eve-Phone: 
City:  Age: 
State:  Occupation:   
Zip:  You: 
* Email:  Spouse: 

Check off any of the following symptoms you have experience in the past 6 months.
Headaches / Tension Fatigue / Tired Digestive Disorder
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 Hip Pain
Pain Other Ringing in Ears Nervous
Tension Across Shoulders Numbness in Arms / Hands Numbness in Legs / Feet
Weight Trouble Allergies Other

Which of the above bothers you the most?

How long have you been bothered by this condition?

Describe how it feels when it is at its worst.

Does this cause:
Being Moody Irritability Interrupted Sleep
Restricted Activities Loss of Patience Poor Decision Making
Poor Attitude Decreased Productivity Exhaustion

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. ACUPUNCTURE AND CHINESE HERBAL MEDICINE CAN HELP YOU because they gently and naturally treat the body to remove the stress and imbalances that CAUSE health problems.

If you would like to rid yourself of these problems, there are several alternatives:
I would like to come to the office for an initial evaluation and consultation.
I would like to attend your wellness classes.
I would like you to call me to discuss my health problems before making an appointment.

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