Please print this free health survey and bring it in on your visit
Health/Stress Survey
Name Age Phone
Address City State Zip
Email Address
1.) Circle the number of any of the following symptoms you have experienced in the past 6 months
A.) Low back H.) Shoulder pain O.) Weight trouble
B.) Neck pain I.) Hip pain P.) Tension Across Shoulders
C.) Pain between shoulders J.) Knee pain Q.) Tingling/Numbing Arms or Hands
D.) Tension/Headaches K.) Ankle/Foot pain R.) Tingling/Numbness in Legs or Feet
E.) Tired or fatigued L.) Ringing in ears S.) Dizziness
F.) Wrist/Hand pain M.) Allergies T.)Nervousness
G.) Elbow Pain N.) Digestive Troubles U.) Difficulty Sleeping
2.) Which one of the above symptoms is the worst? How long have you had it?
3.) Circle how it causes you to act.
A.) Moody B.) Irritable C.) Interrupts sleep D.) Restricts daily activity E.) Other
4.) How does it affect you at work?
A.) Decision Making B.) Exhausted at end of day C.) Decreased Productivity D.) Poor Attitude E.) Unable to work long hours F.) Other
5.) How does it affect your life at home?
A.) No patience with spouse or children B.) Hinders ability to exercise C.) Restricted household duties D.) Interferes with ability to participate in hobbies or other desired activities E.) Other
If you circled any of the above items then you could be suffering from Excessive stress, Structural Misalignment or Pinched nerves. Chiropractic care can help you because we treat the body naturally, gently and without drugs to remove the stress and imbalances that cause health problems.
Would you like to try Chiropractic care to get rid of the problem? Yes No
If your answer is YES, there are several alternatives available to you. Please circle the item most appropriate to you.
1.) I would like to come to the doctor’s office for a complete evaluation.
2.) I would like to come to a class on STRESS and WELLNESS.
3.) I would like the doctor to call me to discuss my health problems before making an appointment.
Please print this health survey back and send to
Advanced chiropractic of south Florida 5063 10th Ave N. Greenacres Fl, 33463 (561) 432-1399 or fax to (561) 432-1388
