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 daily/weekly 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 constant or regular shoulder, hip, elbow or knee pain?

Do you suffer from allergies, asthma or other breathing difficulties?

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 nervous or stressed-out on a regular basis?

Do you have high blood pressure, heart disease, ulcers, colitis or other stress related disease?

Do you feel sick often?

Do you experience regular stomach pain?

Do you have frequent pain for an unknown cause, such as sciatica "pain in buttocks and down back of leg?"?

Are your joints stiff or sore upon arising?

Do your hands or feet tingle, ache, burn or feel numb at any time?

Do any of your health problems affect your work or family life?