Advanced Chiropractic Therapy

1317 El Prado Ave.

Torrance, CA 90501

Phone: 310.381.0024

2950 W. Burbank Blvd.

Burbank, CA 91505

Phone: 818.845.2033

info@back4wellness.com

Toyota Employee Special

Independent Distributor

Free Newsletter

Take the Stress Test

The purpose of this stress survey is to determine if any health problems you may be having are due to stress.

* Indicates Required Fields

*First Name :

*Last Name :

*Email :

*Address :

*City :

*State :

*Zip :

*Occupation :

*Phone :

Working Hrs Weekly hrs

Spouce Occupation

Spouce Working Hrs/Week hrs

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

Other :

Headache/Pain Between Shoulders

Knee Pain

Ankle/Foot Pain

Ringing in Ears

Nervousness

Dizziness

Allergies

Tension Across Top of Shoulders

Numbness/Tingling in Arms or Hands

Numbness/Tingling in Legs or Feet

Weight Trouble

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) Do the symptoms cause you you to be:

Moody

Irritable

Interrupts Sleep

Restricted on Daily Activities

3) In what ways do the symptoms affect your work?

Difficulty Making Decisions

Poor Attitude

Decreased Productivity

Exhausted at End of Day

Unable to Work Long Hours

4) How does this affect your life?

Lose Patience with Spouse or Children

Restricts 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:

· Excessive Stress ·

· Structural Misalignment ·

· Pinched Nerves ·

We Can Help You because we gently treat your body, naturally, without drugs 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 alternatives available to you. Please check the item most appropriate for you.

I would like to come to Advanced Chiropractic Therapy for a complete evaluation. Please call me to schedule an appointment

I would like to come to a class on Stress and Wellness.

I would like Advanced Chiropractic Therapy to call me to discuss my health problems before making an appointment

I am interested in receiving more information from Advanced Chiropractic Therapy.