A new beginning ...  balance ....  to improve your quality of life 
 Opus Acupuncture 66 Nooseneck Hill Rd. W. Greenwich, RI 02817 401-397-6333
 


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Stress Level Survey

This survey is to determine if any health problems you may have are caused by stress. You may:

   1. Complete the Survey On-Line and E-Mail to Dr. O'Brien. (See more below.)
                         or
2. Print the form using the Print function on your Browser (See more below.)

 No information will be disclosed to anyone not directly  employed by us.


 
 

Name:   Age:    Home Phone:   Work Phone:
Address:   City:   ST:   ZIP:
Occupation:   # Hours currently working each week: 


1. Check any of the following symptoms you have experienced in the past 6 months.

  Headache/tension
  Fatigue/Tired
  Pain anywhere  
  Digestive Disturbance        
  Difficulty Sleeping                  
  Irritability
  Allergies
  Weight Issues          
  Dizziness
 

   Pain In:
  Low Back
  Neck
  Wrist/Hand
  Elbow
  Shoulder
  Hip/Knee
  Ankle/Foot
  Between
        Shoulder Blades 		  Numbness/Tingling In:
  Arms or Hands
  Legs or Feet


  Ringing in Ears
  Nervousness


  Tension Across Top of Shoulders
  Other:
  Which of the above bothers you most?
  How long have you been bothered by this condition?
  Describe how it feels or effects you at its worst?

1. Does this cause you to?
    Select all applicable.
  Be Moody
  Be Irritable
  Have Sleep Interruptions
  Restrict Daily Activities
 2. Does it affect your work?
    Select all applicable.
   Decision Making
   Poor Attitude
   Decreased Productivity
   Exhausted at Day's End
   Unable to Work Long Hours		 3. Does it affect your life?
    Select all applicable.
  Lose Patience with Spouse/Children
  Restricted Household Duties
  Hinders Ability to Exercise/Play Sports
  Hinders Ability to Engage in Hobbies
         or Other Desired Activities
   Other

If you checked one or more of the above, your body may not be functioning as well as it could
because your body's energy may not be flowing as smoothly as it could.


Acupuncture can help you. It gently and naturally treats the body to remove the stress and imbalances that CAUSE the problems.


If you would like to get rid of the problem you may follow either of the steps below.

  1. Click the Submit Button (below) to E-Mail the completed form to Dr. O'Brien. Once he has
      reviewed it he will contact you to discuss your situation and schedule a visit. 

  2. Use the Print function on your Browser to print the form. Then call 397-6333 to schedule a visit 
      to discuss your concerns with Dr. O'Brien. (Be sure to bring your completed from with you.)