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Olympic Stress Survey

•Full Name: •Phone: •Address: •State/Prov: Please Select... Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory •Age: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 Work Phone: •City: •Zip/Postal: Your Occupation: Spouse Occupation: Your # Hours Per Week Working: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Spouse # Hours Per Week Working: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Check off any of the following symptoms you have experienced in the past 6 months. Headaches/Migraines Fatigue Weight Trouble Pain/Tension/Numbness in the: Neck Hands Shoulders Arms Legs Low Back Insomnia/Sleep Problems Irritability Sinus Problems/Allergies Digestive Trouble Bloating Gas Diarrhea Constipation Menstrual Problems Asthma Bladder Trouble Ringing in Ears Nervousness Dizziness Other, Please List Which of the above bothers you the most? Please Select... Arms Asthma Constipation Bladder Trouble Bloating Diarrhea Digestive Trouble Dizziness Fatigue Gas Hands Headaches/Migraines Insomnia/Sleep Problems Irritability Legs Low Back Menstrual Problems Neck Nervousness Other... Ringing in Ears Sinus Problems/Allergies Shoulders Weight Trouble How long have you been bothered by this? Please Select... One Week or Less One Month Six Months One Year Longer then a Year Describe how it feels when it is at its worst: Does this cause you to be: Moody Irritable Interrupt Sleep Restricted on Daily Activities Does this affect your work: Decision Making Poor Attitude Decreased Productivity Exhausted at End of Day Unable to Work Long Hours 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: • Excessive Stress • Structural Misalignment • Pinched Nerves Chiropractic can help you because Chiropractic Doctors gently treat the body, naturally, without drugs to remove the stress and imbalances that CAUSE health problems. If you could eliminate one of the above which would it be? There are several alternatives available to you. Please check the item most appropriate for you. I would like to come to the Doctor's office for a complete evaluation. There is NO CHARGE for this examination. 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. • Required Fields

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