Hood River:
541-387-HEAL (4325)

The Dalles:
541-298-BEST (2378)

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


























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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 a 15 minute consultation with the Acupuncturist at NO CHARGE before submitting the survey.

Most of the time it will be possible to schedule this appointment with Carola Stepper, LAc, the owner of Cascade Acupuncture Center, LLC.

This would involve:

  • A tour of the clinic and herbal pharmacy.
  • Chinese Medical Pulse Diagnosis.
  • Brief discussion of your health concerns.
  • Possible treatment suggestions, in our clinic or with other providers.
  • Informational handouts on applicable herbal formulas.
  • Samples of our nutritional supplements – our clients are losing 5 – 7 pounds per week!
  • Complementary insurance verification and explanation of Acupuncture insurance coverage or fee schedule, as applicable
    (To clarify: You will not receive an Acupuncture treatment during this consultation)

You are not obligated to anything at the conclusion of your visit.

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 and we believe in educating our clients on their care options.


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 a FREE 15 minute 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, please add me to your monthly email newsletter, so I can stay informed about upcoming classes.
How did you hear about us?
Link from another website:
Site:
Online Newspaper ad
Yellow Pages
Internet search
Other



© 2005-2010 Cascade Acupuncture Center LLC,
PO Box 556, Hood River, OR 97031
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