| YES |
NO |
|
 |
|
Do you take pain relievers, antacid, tranquilizer, sinus
or any other relief oriented medicine more than 2 times weekly? |
|
|
Have you ever been in an auto accident or taken a bad
fall? |
|
|
Do you have neck or back pain more than 2 times monthly? |
|
|
Do you feel fatigued late in the day? |
|
|
Do you suffer from arthritis? |
|
|
Do you have chronic digestive problems? |
|
|
Have you had pain between the shoulder blades for more
than a month? |
|
|
Do you suffer from headaches or migraines more than 2
times per month? |
|
|
Do you have chronic shoulder, hip, elbow or knee pain? |
|
|
Do you suffer from allergies, asthma or other breathing
problems? |
|
|
Do you have insomnia or feel you don’t sleep enough? |
|
|
Do you get a cold or flu more than 2 times per year? |
|
|
Do you feel you are a nervous or stressed-out person? |
|
|
Do you have high blood pressure, heart disease, ulcers,
colitis, or other stress related disease? |
|
|
Do you experience stomach pain? |
|
|
Do you have frequent pain for an unknown cause, such as
sciatica? |
|
|
Are your joints stiff or sore upon arising? |
|
|
Do your hands or fee tingle, ache, burn or feel numb at
any time? |
|
|
Do any of your health problems affect your work or family
life? |
