Take the INMC Health Survey - SOPHIA Natural Health

Take the SOPHIA Natural Health Center - Integrative Natural Medicine Health/Stress Survey

How Healthy Are You?

Fill Out the Health/Stress Survey Below.

Please fill out the following health survey. Upon completion click the “Submit” button. INM (SOPHIA Natural Health Center) will keep your information in strict confidence. We never share or give out your information. Our consultant will contact you to book your initial consultation and health evaluation.

STRESS SURVEY PURPOSE: To determine if any health problems you may be having are due to stress.

INM Health Survey

Check off any of the following symptoms you have experienced in the past 6 months:

Headaches/Tension

Low Back Pain

Pain Between Shoulder Blades

Allergies

Weight Trouble

Fatigue/Tired

Neck Pain

Shoulder Tension

Pain anywhere in the body

Wrist/Hand Pain

Ankle/Foot Pain

Numbing in Arms

Digestive Disturbance

Elbow Pain

Ringing in Ears

Numbing in Legs

Insomnia/Sleep Problems

Shoulder Pain

Nervousness

Irritability

Hip Pain

Dizziness

Other

Which of the previous conditions bothers you the most?

How long have you been bothered by the condition?

Describe how it feels or affects you when it is at its worst:

Does this cause you to be:

Moody

Irritable

Interrupt Sleep

Restricted on Daily Activities

Other

Does this affect your work:

Decision Making

Poor Attitude

Decreased Productivity

Exhausted at End of Day

Unable to Work Long Hours

Other

Does this affect your life:

Lose Patience with Spouse or Children

Restricted Household Duties

Hinders Ability to Exercise or Participate in Sport

Interferes with Ability to Participate in Hobbies or Other Desired Activities

Other

Any other health concerns?

First Name:

Last Name:

Address:

Address (line 2):

City:

State/Province:

Postal/Zip Code:

Country:

Phone Number:

Email Address:

Occupation: (Optional)

# hours per week currently working:

Occupation of Spouse: (Optional)

# hours per week currently working:

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Take the SOPHIA Natural Health Center - Integrative Natural Medicine Health/Stress Survey

How Healthy Are You?

Fill Out the Health/Stress Survey Below.

INM Health Survey

Check off any of the following symptoms you have experienced in the past 6 months:

Which of the previous conditions bothers you the most?

How long have you been bothered by the condition?

Describe how it feels or affects you when it is at its worst:

Does this cause you to be:

Does this affect your work:

Does this affect your life:

How healthy are you?

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