Stress Survey

Fill Out the Stress Survey Below and Receive an Initial Evaluation at $20 (a $250 Value)

Yes. The above time works.
No. I need additional options.
Acupuncture & Holistic Health Associates of Milwaukee will keep your information in strict confidence. This survey will be used only to help our Milwaukee holistic healing experts determine the causes of your health problems getting you on the Milwaukee highway to a healthier, happier and more balanced you.
stress test 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” button at the bottom of the form when done. Thank You!
STRESS SURVEY
*Name: Age:
*Phone(H):
 Phone(W):
Address: City: State: Zip Code:
Occupation: Work Hours p/ Week:
Spouse’s occupation: Spouse’s Work Hours p/ Week:
*Email Address:
1. Check off any of the following symptoms you have experienced in the past 6 months:
Headaches/Tension Low Back Pain Pain Between Shoulder Blades Allergies
FatigueTired Neck Pain Knee Pain Weight Trouble
Pain Anywhere in the body Wrist/Hand Pain Ankle/Foot Pain Shoulder Tension
Digestive Disturbance Elbow Pain Ringing in Ears Numbing in Arms
Insomnia/Sleep Problems Shoulder Pain Nervousness Numbing in Legs
Irritability Hip Pain Dizziness Other:
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, your organs are probably not functioning as well as they could, and your energy is probably not flowing as smoothly as it could be.

ACUPUNCTURE and CHINESE HERBAL MEDICINE CAN HELP YOU

Because they gently and naturally treat the body to remove the stress and imbalance that cause health problems.
Would you like to get rid of the problem?

Yes

No
If your answer is Yes, there are several alternatives available to you. Please check the item most appropriate for you:
I would like to come to the Acupuncturist’s office for an initial evaluation and consultation.
I would like to come for further wellness classes
I would like the acupuncturist to call me to discuss my health problem before making an appointment.
How did you get to our website, friend, search engine (which?)
Would you like to schedule an appointment?
We have an available time at: 11:00am next Wednesday

Would that time work for you? If so, click ‘yes.’ If not, click ‘Need additional options’ and we will call you with options to fit your schedule.
Stress affects Milwaukee residents in many ways. Is your job performance suffering? Do you rush to and from work with every day seemingly ending in complete fatigue? If you wake up feeling un-rested or can’t sleep due to chronic allergies consider; stress is proven to increase blood pressure, contributes to un-restful sleep, causes fatigue and many serious health problems even leading to depression if not managed.

It could be as simple as frustration over the horrible traffic commuting to work in Milwaukee or a low level irritation of a tennis or softball injury that just won’t completely go away or the nagging irritation of lower back pain brought on my snow shoveling or seasonal Wisconsin yard work.

If your problems are stress related the team at Acupuncture & Holistic Health Associates of Milwaukee will relieve your stress with comparatively un-invasive, drug free acupuncture treatment. Acupuncture helps to relieve pain through the release of endorphins. Acupuncture has been found to increase T-cells aiding in the reduction/elimination of allergy symptoms and chronic fatigue in many patients.