Free Seminars and Education on Acupuncture

STRESS SURVEY

What Health Issues
can Acupuncture Treat?


	Chinese energy hand, abstract meridian points, painted with Chinese characters.

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TAKE OUR FREE STRESS SURVEY

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.