By completing this survey, you qualify to receive a new patient information packet

1) Check off any of the following symptoms you have experienced in the past 6 months:

Headache/Tension Fatigue/Tired Pain Anywhere in Body Digestive Disturbance Difficulty Sleeping Irritability Low Back Pain Neck Pain Wrist/Hand Pain Elbow Pain Shoulder Pain Hip Pain

Pain Between Shoulders Knee Pain Ankle/Foot Pain Ringing in Ears Nervousness Dizziness Allergies Tension Across Top of Shoulders Numbing/Tingling in Arms or Hands Numbing/Tingling in Legs or Feet Weight Trouble Other

Which 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.

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 Sports
Interferes with Ability to Participate in Hobbies or other Desired Activities

If you checked any of the above items, then you could be suffering from:

Would you like to get rid of the problem? Yes   No
If your answer is Yes, there are alternatives available to you. Please check the item most appropriate for you.