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Complete this survey to help us assist you better:
1) Check off any of the following symptoms you have experienced in the past 6 months:
Which of the above bothers you the most?
How long have you been bothered by this condition?
Describe how it feels or affects you when it is at its worst.
Please describe the measures you have taken to find relief so far (therapies and treatments).
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
If you checked any of the above items, then you could be suffering from:
· Excessive Stress ·
· Structural Misalignment ·
· Pinched Nerves ·
We Can Help You because we gently treat your 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 your answer is Yes, there are alternatives available to you. Please check the item most appropriate for you.
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