Health & Wellness Survey

* Name:
Street Address:
City:
State:
Zip:
* Email:
Phone:
Occupation
Hrs Per Week
Spouse Occupation
Hrs Per Week

Check off any of the Following Symptoms you have experienced in the past 6 months:

Pain/Tension/Numbness

1.
Neck
Shoulder
Low Back
Legs
Arms
Hands

Check all that apply

2.
Headaches/Migraines
Fatigue
Insomnia/Sleep Problems
Irritability
Digestive Trouble
Constipation/Diarrhea
Gas/Bloating
Sinus Problems/Allergies
Menstrual Problems
Asthma
Bladder Trouble
Ringing in Ears
Nervousness
Dizziness
Other
Which of the above bother you the most?
3.

How long have you been bothered by the condition?

4.

Describe how it feels or affects you when it is at its worst

5.

Does this cause you to be:

6.
Moody
Irritable
Disruptive Sleep
Restricted on Daily Activities

Does this affect your work:

7.
Decision Making
Poor Attitude
Decreased Productivity
End of Day exhaustion

Does this affect your life:

8.
Lose patience w/ Spouse or Children
Restricted Household Duties
Hinders Ability to Exercise
Interferes w/ Hobbies or other activities

*required information