Stress Survey

We all experience stress in our lives. Some amount of stress can be beneficial, but excess stress can be harmful. If you are experiencing any of the symptoms below, stress might be affecting you adversely.

Acupuncture is a safe, effective treatment for many of the symptoms of stress.

Fill out this questionnaire and bring it with you to receive 20% off of your first visit.

1. Have you experienced any of the following symptoms in the past 6 months?
Headaches Fatigue Night sweats Irritability
Nervousness /
      anxiety		 Sadness /
      depression		 Sleep disturbance Trouble focusing at work
Shortness of breath Upset stomach Diarrhea or constipation Relationship difficulties
Weight gain or loss PMS Neck pain Shoulder pain
Back pain Hip pain Knee pain Foot pain
Muscle ache Change in
      appetite		 Lack of interest in hobbies Recent trauma or personal
      loss
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 Restricted on Daily Activities Sleep deprived
       
3. Does this affect your work:
Decision making Poor attitude Decreased productivity Exhausted at end of day
Unable to work long hours Inability to concentrate  
       
4. Does this affect your home life?
Do you lose patience with your spouse or children?
Do physical limitations impair your ability to do household chores?
Are you unable to play sports or exercise because of pain or fatigue?
Are you unable to participate in hobbies or other desired activities?
 
If you checked any of the above items, your body may not be functioning optimally and your energy is probably not flowing smoothly. ACUPUNCTURE and NUTRITIONAL SUPPORT may help you because they naturally treat the body to remove the stress and imbalance that cause health problems.
 

   

 

The Acupuncture Alternative
7505 Lilac Sea
Columbia, MD 21046
(410) 381-3495