Fill Out the Stress Survey Below and
Receive an Initial Evaluation at $20 (a $250 Value)

Date:		*Name:	Age:
Address:	City:
State:	Zip: *Email:
*Phone:	Mobile:
Occupation:	# of Hours/Week spent @ work:

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
Fatigue/Tired	Neck Pain	Knee Pain	Shoulder Tension
Shoulder Pain	Elbow Pain	Wrist/Hand Pain	Ankle/Foot Pain
Hip Pain	Pain Anywhere in the Body	Numbing in Arms	Numbing in Legs
Ringing in Ears	Dizziness	Nervousness	Insomnia/Sleep Problems
Irritability	Weight Gain	Digestive Disturbance	Other:

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	Decreased Productivity	Unable to Work Long Hours
Poor Attitude	Exhausted at the End of the 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, your organs are probably not functioning as well as they could, and your energy is probably not flowing as smoothly as it could be.

5. How long have you been trying to either lose weight or improve your physical health?
6. What programs have you tried?
7. Out of all of these programs, which ones did you stick with and why?

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 the Acupuncturist's office for an initial evaluation to see if acupuncture can help me.
	I would like to come for further wellness classes.
	I would like the acupuncturist to call me to discuss my health problem before making an appointment.

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Note: All information is kept in strict confidence and we never share or give out your information.

Fill Out the Stress Survey Below and Receive an Initial Evaluation at $20 (a $250 Value)

Fill Out the Stress Survey Below and
Receive an Initial Evaluation at $20 (a $250 Value)