Stress Survey from Summit Family Chiropractic

Stress Survey

The Summit Family Chiropractic Stress Survey is to determine if you have any health problems due to stress. Please fill out the survey below and we will be in touch with you as soon as possible. All information is strictly confidentional and is only used to assist the patient. ( * required fields)

Basic Information
Name *
Address
City
State
Zip
Phone *
Email *
Age
Occupation		Work Hours Per Week
Spouse's Occupation		Work Hours Per Week

Does this cause you to be:
	Restricted on Daily Activities		Moody		Interrupted Sleep		Irritable

Does this affect your work:
	Decision Making	Unable to Work Long Hours	Exhausted at End of Day
	Poor Attitude	Decreased Productivity

Does this affect your life:
	Restricted Household Duties	Lose Patience with Spouse or Children
	Hinders Ability to Exercise or Participate in Sport	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 one of the following:

EXCESSIVE STRESS	STRUCTURAL MISALIGNMENT	PINCHED NERVES

CHIROPRACTIC CAN HELP YOU! Chiropractic Doctors gently treat the body, naturally, without drugs to remove the stress and imbalances that cause health problems.

Course of Action:
	I would like to come to the Doctor's office for a complete evaluation. This will allow me to find out if I can be helped by Chiropractic without any financial barriers.
	I would like the Doctor to call me to discuss my health problems before making an appointment.


Are you a member of an HMO or Health Care Network?	Yes No
Name of HMO (if applicable):

Would you like to receive the Summit Family Chiropractic Newsletter?	Yes No