scottsdale acupuncture
Rate Your Wellness Survey

PURPOSE:
To determine your current state of health.

Please fill out the following information and click the "Submit My Stress Survey!" button at the bottom of the form when done:
Your Information
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/Tension Low Back Pain Pain Between Shoulder Blades Allergies
Weight Trouble
FatigueTired Neck Pain Knee Pain Shoulder Tension
Pain Anywhere in the body Wrist/Hand Pain Ankle/Foot Pain Numbing in Arms
Digestive Disturbance Elbow Pain
Ringing in Ears
Numbing in Legs
Insomnia/Sleep Problems Shoulder Pain Nervousness Other:
Irritability Hip Pain Dizziness
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 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 Sport
Interferes with Ability to Participate in Hobbies or Other Desired Activities
If you checked any of the above items, your organs are probably not functioning as well as they could, and your energy is probably not flowing as smoothly as it could be.
ACUPUNCTURE and CHINESE HERBAL MEDICINE CAN HELP YOU because they grant and naturally treat the body to remove the stress and imbalance that cause health problems.
Would you like to get rid of the problem? Yes No
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 see the Doctor for a consultation and screening. There is NO CHARGE for this visit. This will allow The Get Well Center to find out if or how you can be help without any financial barriers.
I would like to come for further wellness classes or lectures.
 

 
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