Stress TestPersonal InformationName*AgePhone*Email* Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OccupationHours Worked Per WeekSpouse's OccupationHours Worked Per WeekSymptomsCheck all that apply Headache/Tension Digestive Disturbance Low Back Pain Elbow Pain Nervousness Ringing in Ears Allergies Knee Pain Neck Pain Fatigue/Tired Difficulty Sleeping Pain Anywhere in Body Shoulder Pain Ankle/Foot Pain Numbing/Tingling in Arms or Hands Tension Across Top of Shoulders Pain Between Shoulder Blades Numbing/Tingling in Legs or Feet Wrist/Hand Pain Irritability Weight Trouble Hip Pain Allergies Dizziness Other symptomsOther SymptomsWhich of the above bothers you the most?How long have you been bothered by this condition?Describe how it feels or affects you when your symptoms are at their worstEffectsWhich of the following do you experience as a result of your symptoms? Moody Irritable Interrupt Sleep Restricted on Daily ActivitiesDo the symptoms above affect your work performance? If so, which of the following are affected? Decision Making Poor Attitude Decreased Productivity Exhausted at End of Day Unable to Work Long HoursWhich of the following can be attributed to your symptoms? Lose Patience With Spouse or Children Hinders Ability to Exercise or Participate in Sports Restricted Household Duties Interferes with Ability to Participate in Hobbies or Other Desired ActivitiesResultsIf you checked any of the above items, then you could be suffering from excessive stress, structural misalignment or pinched nerves.We can help you because we gently treat your body, naturally, without drugs to remove the stress and imbalances that cause health problems.If you would like to discuss your symptoms and get information on treatment options then please contact us or let us know the best time to contact you.Please contact me via:EmailPhoneNameThis field is for validation purposes and should be left unchanged.
