Stress Survey

Name
First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Age
Occupation
# Hours per week currently working
Spouse's Occupation
# Hours per week currently working

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?
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