Stress & Digestion Survey for information from Dow Health and Synergy Wellness Center

Stress & Digestion Survey

Welcome to Dow Health's Survey!

Please fill this out the below survey and press the submit button when you are done.

We will due our best to get back to you within 2 business days.

** Note: Name, E-Mail & home phone are required fields so that we can contact you.

Welcome to Dowhealth and Synergy Wellness Center

Name: Age: E-Mail: Address: City: State: Zip: Home Phone# Work Phone# These are required fields so that we can contact you. Occupation: # of Hours currently working Spouse's Occupation: # of Hours currently working

1. Check off any of the following symptoms you have experienced in the past 6 months.
	Acid Reflux/Heartburn	Stomache Pains/Cramping
	Nausea	Fatigue
	Constipation	Bad Breath
	Diarrhea	Burping
	Chronic Coughing	Difficulty Swallowing
	Chest Pain	Burning Sensation
	Shortness of Breath	Pain/Restricted Motion/Numbness
	Loss of Appetite	Neck	Arms
	Vomiting	Shoulders	Hands
		Low Back	Legs
	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 the worst:


2. Does this cause you to be:
	Moody
	Irritable
	Interrupt Sleep
	Restricted Daily Activities
	Top
3. Does this affect your work:
	Decision Making
	Poor Attitude
	Decreased Productivity
	Exhausted at the end of the day
	Unable to work long hours
	Other (please specify)
	Top
4. How does this affect your life:

	Lose Patience with Souse or Children
	Restricted household duties
	Hinders ability to exercise or participate in sports
	Interferes with ability to participate in hobbies or other desired activities
	Top

If you checked any of the above items, you may have nerve interference, your organs are probably not functioning as well as they could, and your energy is probably not flowing as smoothly as it could be. CHIROPRACTIC, ACUPUNCTURE AND CHINESE HERBAL MEDICINE CAN HELP YOU because they gently and naturally treat the body to remove the stress and imbalances 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 most appropriate for you:
	I would like to come to the Doctor's office for an initial evaluation and consultation. There is NO CHARGE for this visit. This will allow me to find out if I can be helped by Chiropractic, Acupuncture and Chinese Herbal Medicine without any financial barriers.
	I would like to come for further wellness classes.
	I would like the Doctor to call me to discuss my health problems before making an appointment.

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Last update: February 6, 2007

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