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Stress Survey

Fill out the Stress Survey below and receive a FREE Initial Evaluation.

Please fill out the following survey. Upon completion click the "Submit My Stress Survey!" button. Healing Grace Acupuncture will keep your information in strict confidence. This survey will be used only to help determine the causes of your health problems.

* denotes required information needed.

First Name*: Last Name*:

Address, City & State:

Age*: Primary Phone*: Alternate Phone:

Email Address*:

Your Occupation: Hours/week currently working:

Your Spouse/Partner's Occupation: Hours/week currently working:

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	Weight Trouble
Pain Anywhere in the body	Wrist/Hand Pain	Ankle/Foot Pain	Numbness in Arms
Digestive Disturbance	Elbow Pain	Ringing in Ears	Numbness in Legs
Insomnia/Sleep Problems	Shoulder Pain	Nervousness
Other:

Which one of the above bothers you the most*:

How long have you been bothered by this condition?*

Describe how it feels or affects you when it is at its worst*:

Does this cause you to be*: Moody Irritable Interrupt Sleep Restricted on Daily Activity

How does this affect your work*:
Decision making
Poor attitude
Decreased productivity
Exhausted by the end of the day
Can't work long hours

How does this affect your personal life*:
Lose patience with spouse or children
Restricted household duties
Hinders ability to exercise or participate in sport(s)
Interferes with ability to participate in hobbies or other desired activities

If you checked any of the above items, your body's circulation is probably not performing optimally.

ACUPUNCTURE and CHINESE HERBAL MEDICINE CAN HELP YOU because these modalities naturally treat the body to remove the imbalances that cause health problems.

Would you like to get rid of your 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 schedule a free initial evaluation to see how acupuncture can help me.
I would like to participate in wellness classes.
I would like the acupuncturist to call me to discuss my health problem before making an appointment.

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