Please take part in our stress test by completing the form below as best you can. Once you have completed all sections click on the Go button and the form will be sent to us. We will then check the form and print it off, ready for your visit to us!

Patient
Date
The following three areas of stress can cause a misaligned vertebra (Subluxation). Do you recognize any of these stresses? Please click on the appropriate box to let us know when you experienced these stresses:
C (Child), T (Teenager), A (Adult), or N (not at all).
I. PHYSICAL STRESS EXPLAIN Birth Traumas (as a mother or child) C T A N Slips and Falls C T A N Car Accidents C T A N Sports Injuries C T A N Physical Abuse C T A N Work Injuries C T A N Poor Posture C T A N Sitting on your Wallet for Years C T A N Sleeping Position - Stomach C T A N Extensive Computer Work C T A N Carrying Heavy Purse/Bag/Child C T A N Repetitive Lifting/Bending C T A N Driving for Many Hours C T A N Continuous Hours of Sitting/Standing C T A N Bone Fracture/Surgery C T A N
II. EMOTIONAL STRESS EXPLAIN Relationships C T A N Career C T A N Children C T A N Money C T A N Fast-Paced Life C T A N Holding In Feelings C T A N Quick Tempered C T A N Verbal Abuse C T A N Perfectionist C T A N Procrastinator C T A N Sickness or Loss of a Loved One C T A N
III. CHEMICAL STRESS EXPLAIN Environment C T A N Smoker? Amount? C T A N Second-Hand Smoke C T A N Poor Diet C T A N Caffeine? Amount? C T A N Excess Sugar/Artificial Sweeteners C T A N Alcohol C T A N Prescription Drugs C T A N Over-the-counter Drugs C T A N

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