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Stress Survey


 


Arvada Accident and Back Pain Clinic
“Initial consultation FREE!”

Stress Survey

Name Age
Address  
Email  
City State/Prov. Zip/Postal
Phone (Home) Phone (Work)
Occupation Hours per week currently working
Spouse Occupation Hours per week currently working

1
 Check off any of the following symptoms you have experienced in the past 6 months:
Headaches/Migrains Insomnia/Sleep Problems Irritability Nervousness
Fatigue Digestive Trouble Sinus Problems/Allergies Dizziness
Pain/Tension/Numbness   Constipation Asthma Weight Trouble
  Neck Legs   Diarrhea Menstrual Problems Other _______
  Shoulders Arms   Gas Bladder Trouble
  Low Back Hands   Bloating Ringing in Ears  
 
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 Sports
  Interferes with Ability to Participate in Hobbies or Other Desired Activities