STRESS SURVEY

To determine if any of your health problems are due to stress.
All information is held in strict confidence.

Name Age

Address

City State Zip

Telephone DAY EVENING

Email

Occupation No. of Hours a week currently working:

Married/Partnership yes no

Spouse's
Occupation No. of Hours a week currently working:

1. Check off any of the following symptoms you have experienced in the past six months:

Headaches/Tension	Low Back Pain	Pain Between Shoulder Blades	Allergies
Fatigue/Tired	Neck Pain	Knee Pain	Tension Across Top of Shoulders
Pain Anywhere in Body	Wrist/Hand Pain	Ankle/Foot Pain	Numbing/Tingling in Arms or Hands
Digestive Disturbance	Elbow Pain	Ringing in Ears	Numbing/Tingling in Legs or Feet
Difficulty Sleeping	Shoulder Pain	Nervous	Weight Trouble
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 effects you when it is at its worst:

2. Does this cause you to be:

Moody

Irritable

Sleeping with Interruptions

Restricted 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 Activities

WOULD YOU LIKE TO GET RID OF THE PROBLEM? yes no

If you answered yes, there are several alternatives available to you. Please check the most appropriate for you.

I would like to come to Dr. Maguire's office for an initial evaluation and consultation. There is NO CHARGE for this visit.
This would allow me to find out if I can be helped by Acupuncture and Oriental Medicine without any financial barriers.

I would like to come to wellness classes.

I would like Dr. Maguire to call me to discuss my health problems before making an appointment.