Welcome!

This new patient offer is our gift to you because our purpose is to help as many people as possible get well naturally.

After you have filled out the stress survey, be sure to select the option to come into our office for an initial evaluation and consultation at NO CHARGE. We will call to schedule your 45 minute health history and evaluation with the Acupuncturist who will discuss your health concerns and possible treatment options with you.

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

All information is kept in strict confidence and we never share or give out your information.

STRESS SURVEY

* items are required

    • Phone(Home):
  • # Hours per week currently working:
  • Spouses occupation:
  • # Hours per week currently working:
  • Email Address*:

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

  • Headaches
  • Back Pain
  • Pain Between Shoulder Blades
  • Weight Trouble
  • Fatigue/Tiredness
  • Neck Pain
  • Whiplash
  • Knee Pain
  • Shoulder Tension or Pain
  • Wrist/Hand Pain
  • Ankle/Foot Pain
  • Numbing in Arms
  • Numbing in Legs
  • Digestive Disturbance
  • Allergies
  • Ringing in Ears
  • Insomnia/Sleep Problems
  • Nervousness
  • Irritability
  • Hip Pain
  • Dizziness
  • 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:

Does this condition cause any of the following:

  • Moodiness
  • Irritability
  • Sleep Disruptions
  • Restricted on Daily Activities

Does this affect your work:

  • Decision Making
  • Attitude
  • Productivity
  • Energy Level
  • Restricted Hours

Does this affect your life:

  • Impatience with Partner or Children
  • Restricted Household Duties
  • Limited Ability to Exercise or Participate in Hobbies

If you checked any of the above items, your organs are probably not functioning as well as they should. Acupuncture can help by improving the flow of blood and energy in the body.

How did you hear about us?

  • Link from another website:
  • Online Newspaper ad
  • Yellow Pages
  • Internet search
  • Other:

To make sure you are a person (and not a robot), please tell me the answer to the following equation: What is the sum of one plus 1? (The answer is two!)