Age 18-30 31-40 41-50 51-65 65+

Phone: Best Time to Call: Morning Afternoon Early Evening Evening

Address: City: Zip:

Occupation:

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

Low Back Pain
Elbow Pain
Tension Across Shoulders
Allergies
Digestive Problems
Ringing in Ears
Difficulty Sleeping
Pain Between Shoulders
Shoulder Pain
Numbing/Tingling in Arms or Hands
Nervous
Numbness/Tingling in Legs or Feet
Weight Trouble
Neck Pain
Hip Pain
Knee Pain
Tension/Headaches
Dizziness
Tired, Fatigued
Ankle/Foot Pain
Wrist/Hand Pain

Which of the above is worst?

How long have you had it?

When it is at its worst, how does it feel?

2) Does this cause you to be:

Moody
Irritable
Interrupt Sleep
Restricted on Daily Activities

3) How does this affect your work?

Decision Making
Poor Attitude
Decreased Productivity
Exhausted at the End of Day
Unable to Work Long Hours

4) How does this affect your life?

Lose patience with spouse or children
Restricted household duties
Hinders ability to exercise or participate in sports
Interfers with ability to participate in hobbies or other desired activities

A WELLNESS CONSULTANT CAN HELP YOU! Our wellness providers gently treat the 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 you answer YES, there are several alternatives available to you. Please check the item most appropriate for you.

I would like to come to the Wellness Center for a complete evaluation.
I would like to come to a class on Stress and Wellness.
I would like a Wellness Consultant to call me to discuss my health problems before making an appointment.