pphcc.com stress test

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Free Health Risk Profile!

PURPOSE:
To determine if any health problems you may be having are due to stress.All information is kept in strict confidence and we never share or give out your information.Please fill out the following information and click the "Submit My Stress Test!" button at the bottom of the form when done: (* required field)

STRESS SURVEY — Part 1

*Name (F):		Name: (L)		*Phone(H):		Phone(W):
*Address:		*City:		*State:		*Zip:

Occupation:		# Hours per week currently working:
Spouse's occupation:		Age:
*Email Address:		Birth Date:

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

Headaches /
Migraines

Insomnia / Sleep
Problems

Menstrual
Problems

Weight
Trouble

Fatigue

Irritability

Asthma

Dizziness

Bladder Trouble

Ringing in Ears

Nervousness

Other:

Pain / Tension /
Numbness:

Digestive
Trouble:

Neck	Legs
Shoulders	Arms
Low Back	Hands

Constipation	Diarrhea
Bloating	Gas

Which of the above bothers you the most?

How long have you been bothered by the 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 Sport

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

THERE ARE SOLUTIONS THAT TREAT THE BODY NATURALLY WITHOUT DRUGS to remove the imbalances that CAUSE health problems and makes you vulnerable to stress.

IF YOU COULD ELIMINATE ONE OF THE ABOVE WHICH WOULD IT BE?

There are several options available to you. Please check the item most appropriate for you:

	I would like a doctor to call me to discuss my health problem & review my stress test.
	I would like someone to call me so I can make an appointment to come into the office and discus my health problem & review my stress test.
	I would like more information about my health condition & stress test.

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