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1921 St. Mary's Road At Britannica

Winnipeg, Manitoba R2N 1J4 Canada

204-253-6995

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Take The Stress Test

Take the Stress Test
The purpose of this stress survey is to determine if any health problems you may be having are due to stress. * indicates required information.

 

*Name
*Age
*Phone (Home)
*Work
*Address
*City, Province/Territory, Postal Code
*E-mail Address
*Occupation
# Hours per week
currently working
Spouse Occupation
# Hours per week
currently working

 

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:

Headache/Tension
Fatigue/Tired
Pain Anywhere in Body
Digestive Disturbance
Difficulty Sleeping
Irritability
Low Back Pain
Neck Pain
Wrist/Hand Pain
Elbow Pain
Shoulder Pain
Hip Pain
Pain Between Shoulders
Knee Pain
Ankle/Foot Pain
Ringing in Ears
Nervousness
Dizziness
Allergies
Tension Across Top of Shoulders
Numbing/Tingling in Arms or Hands
Numbing/Tingling in Legs or Feet
Weight Trouble
Other

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.

I would like to come to River Park South Chiropractic for a complete evaluation. Please call me to schedule an appointment.
I would like to attend for a consultation on Stress and Wellness.
I would like River Park South Chiropractic to call me to discuss my health problems before making an appointment.
I am interested in receiving more information from River Park South Chiropractic.

 

Once completed please fax the above page to our office. We will contact you back shortly.

Same day appointments available.

Sign-up using the form or call us at 204-253-6995 to take advantage of this exclusive offer.

Locations

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Testimonials

Reviews By Our Satisfied Patients

  • "I would like to thank Dr. John for helping me get moving again. If it wasn't for your help I'd still be sockless. I'd also like to thank Dr. Audrey for introducing me to the nearly instantaneous relief of acupuncture and helping me walk without pain again. You two have to be the most caring couple ever. I would have never gotten this far if it wasn't for the two of you. I can't thank you enough."
    - D.M., Winnipeg / Winnipeg, Manitoba
  • "For years I suffered with foot pain that made each step a misery. Dr. John found the problem and he has helped me fix it. Getting customized orthotics for my shoes was an improvement and a treatment plan for my feet keeps me going completely pain free. I really like how Dr. John's office can accommodate my busy work schedule to fit in my treatments."
    M.C., Winnipeg/Winnipeg, Manitoba
  • "I have seen chiropractors all my life. Some chiropractors can be very rushed or very rigid in terms of what types of care they will offer or recommend. The care I received at this office was above and beyond anything I had before. I appreciate the availability and the consistency of care options."
    A.D., Winnipeg/Winnipeg, Manitoba
  • "When I had my car accident, I was shocked at how much pain I was in. I could barely move my neck. Dr. Audrey was there for me. I was surprised at the effect that chiropractic care had on helping me to recover. It seemed that when I would start to stiffen up again, chiropractic treatment would settle things down right away. And this was a really good thing because I couldn't afford to miss opportunities or any time from work. That was two years ago. Even now that the accident case has closed I still see Dr. Audrey every month or two just to keep feeling good."
    C.C., Winnipeg/Winnipeg, Manitoba

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