Stress Survey

To Determine if any Health Problems You May Have Are Due To Stress

Check Off Any of The Following Symptoms You Have Experienced In The Last Six Months



Pain/Tension /Numbness (if so where?)





Low Back


Insomnia/Sleep Problems

Digestive Trouble ( If So What Kind Of Trouble?)






Sinus Problems/Allergies


Menstrual Problems

Bladder Trouble

Ringing In The Ears



Weight Trouble


Insert text box here for write in answers

Which of the Above Bothers You The Most?

How Long Have You Been Bothered By The Conditions?

Describe How It Feels or How It Affects You When It Is At Its Worst

Does This Cause You To Be...




Interrupt Your Sleep?

Restrict Your Daily Activities?

Does This Affect Your Work?

Decision Making?

Poor Attitude?

Decreased Productivity?

Exhausted at The End of The Day?

Unable To Work Long Hours?

Does This Affect Your Life?

Lose Patience With Spouse Or Children?

Restricted Household Duties?

HInders Your Ability To Exercise

Inhibits Your Ability To Participate In Sports?

Interferes With Your Ability To Participate or Other Desired Activities?

Opt in form here?

Please Accept My Personal
Gift To You...

Because I truly care about you and .

Your Health Problems Will Only Get Worse!
Studies Show That The Longer You Wait To Address Your Symptoms The Morely Likely They Are To Get Worse.

You can easily avoid months or even years of needless suffering by dealing with with your problems right now Before They Get Worse.

When We Handle Your Particular Problem. Feeling Great Is What Life Is All About.

My Personal Guarantee!
I Will Not Waste Your Time Or Your Money. If I Can't Help You, I will let you know, You Have Absolutely No Risk!

You Have Nothing To Lose!
Because I am Doing This full consultation and
screening for you as a Gift at no charge.

The gift I am offering you at no charge is your opportunity to see if we can help.

Would You Be Willing To
Accept This Gift?

There are several options available to you. Please check the item most appropriate For You

I would like to come to the Office For a complete evaluation. This will
xxx allow me to find out if I can be helped by Acupuncture without any financial
xxx barriers.

I would like David to call me to discuss my health problems before
xxx making an appointment.

If possible, I would like to see David on:

Monday Tueday Wednesday Thursday Friday Saturday

The following times may or may not be available. Please selecct two options. Our office will call to confirm your appointment

9 a.m. 10 a.m. 11 a.m. 12 noon 2 p.m. 3 p.m. 4 p.m.

5 p.m. 6 p.m..

Proudly Serving:

Solana Beach:

Solana Beach Acupuncture | Solana Beach Acupuncture Doctor | Solana Beach Acupuncture Doctors | Solana Beach Acupuncturist
|Solana Beach Pain Specialist | Solana Beach Pain Clinic | Solana Beach Back Pain |Solana Beach Headache Treatment | Solana Beach Knee Pain Relief
| Solana Beach Heel Pain Treatment | Solana Beach Carpal Tunnel Syndrome |
| Solana Beach Low Back Pain Treatment | Solana Beach | Solana Beach Natural Medicine | Solana Beach Infertility Treatment | Solana Beach | Solana Beach Shoulder Pain | Solana Beach Sciatic Pain San Diego Neck Pain | Solana Beach Hip Pain |
| Ankle Pain, Foot Pain, Leg Pain |


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| Ankle Pain, Foot Pain, Leg Pain |

Del Mar

| Del Mar Acupuncture | Del Mar Acupuncturists | Del Mar Acupuncture Doctors | Del Mar Acupuncturist | Del Mar Acupuncture Recomendations | Del Mar Pain Clinics | Del Mar Pain Management | Del Mar Pain Treatment | Del Mar Pain Specialist | Pain Care Del Mar| Del Mar Low Back Pain Treatment | Del Mar | Del Mar Natural Medicine | Del Mar | Del Mar Shoulder Pain | Del Mar Sciatic Pain Del Mar Neck Pain | Del Mar Carpal Tunnel Syndrome | Del Mar Heel Pain Treatment | Del Mar Knee Pain Relief | Del Mar Hip Pain |
| Ankle Pain, Foot Pain, Leg Pain |