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 Numbing/Tingling in Arms or Hands Numbing/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) Does this cause you to be: Moody Irritable Interrupt Sleep Restricted on Daily Activities
3) Does this affect your work: Decision Making Poor Attitude Decreased Productivity Exhausted at End of Day Unable to Work Long Hours
4) Does this affect your life: Lose Patience with Spouse or Children Restricted 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:
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 Enfield Pain Clinic 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 Enfield Pain Clinic to call me to discuss my health problems before making an appointment.
I am interested in receiving more information from Enfield Pain Clinic.
Once you have completed the Stress Survay, you may fax the servay to us at 860-745-7600. (Please call 860-745-7600 first to let us know and we will accept the fax.)
