Stress Test

The purpose of this stress survey is to determine if any health problems you may be having are due to stress.

* indicates required information.

 

*Name
*Age
*Phone (Home)
*Work
*Address
*City, State, Zip
*E-mail Address
*Occupation
# Hours per week
currently working
Spouse Occupation
# Hours per week
currently working

 

By completing this survey, you qualify to receive a new patient information packet.

1) Check off any of the following symptoms you have experienced in the past 6 months:

Headache/Tension

Fatigue/Tired

Pain Anywhere in Body

Digestive Disturbance

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

Ringing in Ears

Nervousness

Dizziness

Allergies

Tension Across Top of Shoulders

Numbness/Tingling in Arms or Hands

Numbness/Tingling in Legs or Feet

Weight Trouble

Other

Which of the above bothers you the most?

How long have you been bothered by this condition?

Describe how it feels or affects you when it is at its worst.

2) Do the symptoms cause you you to be:

Moody

Irritable

Interrupts Sleep

Restricted on Daily Activities

3) In what ways do the symptoms affect your work?

Difficulty Making Decisions

Poor Attitude

Decreased Productivity

Exhausted at End of Day

Unable to Work Long Hours

4) How does this affect your life?

Lose Patience with Spouse or Children

Restricts Household Duties

Hinders Ability to Exercise or Participate in Sports

Interferes with Ability to Participate in Hobbies or other Desired Activities

If you checked any of the above items, then you could be suffering from:

· Excessive Stress ·
· Structural Misalignment ·
· 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. Would you like to get rid of the problem?
Yes  
No
If your answer is Yes, there are alternatives available to you. Please check the item most appropriate for you.
I would like to come to Family Life Chiropractic for a complete evaluation. Please call me to schedule an appointment.
I would like to come to a class on Stress and Wellness.
I would like Family Life Chiropractic to call me to discuss my health problems before making an appointment.
I am interested in receiving more information from Family Life Chiropractic.

 


  • Testimonial – Carole R.

    "My allergies, digestion, joints and my overall health has greatly improved!"

  • Testimonial – Bernie G.

    "Not only did I feel great throughout my pregnancy, but I know that my labor went easily because of chiropractic. Now I tell every pregnant woman to get to a chiropractor!"

  • Testimonial – Barbara I.

    "I made my first chiropractic appointment out of desperation. Even though I had completed Kaiser's 10-week back care program, my back and hips still hurt so much that I could not sleep at night. My health deteriorated because I was exhausted due to lack of sleep, and I cried at night because nothing I did alleviated the pain. My first chiropractic adjustment gave me instant relief. After a few appointments I felt good again."

  • Testimonial – Charley T.

    "I urge all the people I know personally to seek chiropractic treatment. It works wonders!"

Ask The Doctor

If you are seeking chiropractic care in San Jose, we know you’ll have lot of questions. For your convenience, we would like to take the time to answer the most commonly asked questions below.
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Healthy Back Tips

Maintaining a healthy spine is vital to your health and well-being. In between regular visits to your chiropractor, here are the top 10 things you can do to keep your spine healthy and free of pain and discomfort.
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Family Life Chiropractic in San Jose

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