Hood River:
541-387-HEAL (4325)

The Dalles:
541-298-BEST (2378)

Carola Stepper, LAc, RN retired
& Associates
heal@CascadeAcupuncture.org



















Sign up for our
email Newsletter



New Client Offer & Stress Survey:

Welcome! This new client offer is our gift to you.

After you have filled out the stress survey, be sure to select the option to come into our office for an initial
evaluation and consultation at NO CHARGE before submitting the survey.
We will call to schedule your 45 minute evaluation and consultation at NO CHARGE or OBLIGATION with the Acupuncturist who will discuss your health concerns and our treatment suggestions for you.

We are offering this gift to you because our purpose is to help as many people as possible
to reach their optimal level of health naturally.

The Purpose of this STRESS SURVEY is
to determine if any health problems you may be having are due to stress.

All information is kept in strict confidence and we never share or give out your information.

Please fill out the following information and click the "Submit My Stress Survey!"
button at the bottom of the form when done:
STRESS SURVEY
*Name:
*Age:
Phone(H):
Phone(W):
Address:
City:
State:
Zip Code:
Occupation:
# Hours per week currently working:
Spouse's occupation:
# Hours per week currently working:
*Email Address:
    
1. 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 Knee 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 Other:
Irritability Hip Pain Dizziness
Which of the above 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:
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 Sport
Interferes with Ability to Participate in Hobbies or Other Desired Activities
If you checked any of the above items, your organs are probably not functioning as well as they could, and your energy is probably not flowing as smoothly as it could be.
ACUPUNCTURE and CHINESE HERBAL MEDICINE CAN HELP YOU because they grant and naturally treat the body to remove the stress and imbalance that cause health problems.
Would you like to get rid of the problem? Yes No
If your answer is Yes, there are several alternatives available to you. Please check the item most appropriate for you:
I would like to come to the Acupuncturist’s office for an initial evaluation and consultation. There is NO CHARGE for this visit. This will allow me to find out if I can be helped by Acupuncture and Chinese herbal Medicine without any financial barriers.
I would like to come for free wellness classes
I would like the Acupuncturist to call me to discuss my health problem before making an appointment.
How did you hear about us?
Link from another website:
Site:
Online Newspaper ad
Yellow Pages
Internet search
Other


© 2005-2007 Cascade Acupuncture Center LLC,
PO Box 556, Hood River, OR 97031
Privacy Statement		 Web Design:: GorgeOnline.com