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Stress Test

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Stress Test

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 information.

*Name:
*Age:
*Email:
*Phone:	-
*Occupation:

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

Which of the above bothers you the most?

How long have 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
	Interferes With 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 without drugs to remove the stress and imbalances that cause health problems.

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

	I would like to come to California Chiropractic for a complete evaluation. Please call me to schedule an appointment.
	I would like California Chiropractic to call me and discuss my health problems before scheduling an appointment.
	I am not ready to proceed at this time.

or Cancel

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California Chiropractic

Restore Your Health. Reclaim Your Life.

New Patients

Make An Appointment

Stress Test

Take the Stress Test

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

2) Does this cause you to be:

3) Does this affect your work:

4) Does this affect your life:

We Can Help You...