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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.
