PURPOSE:
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.

Please fill out the following information and click the "Submit My Stress Survey!" button at the bottom of the form when done:
STRESS SURVEY
Name:
Age:
Phone(H):
Phone(W):
Address:
City:
State:
Zip Code:
Occupation:
# Hours per week currently working:
Spouse's occupation:
# Hours per week currently working:
Email Address:
    
1. Check off any of the following symptoms you have experienced in the past 6 months:
Headaches/Migraines Insomnia/Sleep Problems Menstrual Problems Weight Trouble
Fatigue Irritability Asthma Dizziness
Bladder Trouble Ringing in Ears Nervousness Other:
Pain/Tension/Numbness Digestive Trouble  
Neck Legs Constipation Diarrhea
Shoulders Arms Bloating Gas
Low Back Hands    
Which of the above bothers you the most?

How long have you been bothered by the condition?

Describe how it feels or affects you when it is at its worst:
2. Does this cause you to be:
Moody Irritable Interrupt Sleep Restricted on Daily Activities
3. Does this affect your work:
Decision Making Poor Attitude Unable to Work Long Hours
Decreased Productivity Exhausted at End of Day  
4. Does this affect your life:
Lose Patience with Spouse or Children
Restricted Household Duties
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:
• 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?
If your answer is Yes, 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. 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):




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Clark Chiropractic Center
418 East Diamond Avenue • Gaithersburg, MD 20877
301-926-1500
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