Texas Spine and Sports Therapy Center offers our patient form(s) online so they can be completed it in the convenience of your own home or office.
- If you do not already have AdobeReader® installed on your computer, Click Here to download.
- Download the necessary form(s), print it out and fill in the required information.
- Fax us your printed and completed form(s) or bring it with you to your appointment.
New Patient Health History Form - Required
This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!
Download & Print FormMember Wellness Registration Form - Optional
This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!
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Determine Your Stress Level
Check all events that apply to you, that have occurred over the past twelve months. Adapted from the "Social Readjustment Rating Scale" by Thomas Holmes and Richard Rahe. This scale was first published in the "Journal of Psychosomatic Research", vol.II p. 214. 100___Death of a Spouse 73____Divorce 65____Marital Separation 63____Jail Term 63____Death of close family member 53____Personal Injury or illness 50____Marriage 47____Fired at work 45____Marital reconciliation 45____Retirement 44____Change in health of family member 40____Pregnancy 39____Sex difficulties 39____Gain of new family member 39____Business Readjustment 38____Change in financial state 37____Death of a close friend 36____Change to different kind of work 35____Change in number of arguments with spouse 31____Mortgage over $10,000 30____Foreclosure of mortgage or loan 29____Change in responsibilities at work 29____Son or daughter leaving home 29____Trouble with in-laws 28____Outstanding personal achievement 26____Spouse begins or stops work 26____Begin or end school 25____Change in living conditions 24____Revision of personal habits 23____Trouble with boss 20____Change in work hours or conditions 20____Change in residence 20____Change in schools 19____Change in recreation 18____Change in church activities 18____Change in social activities 17____Mortgage or loan less than $10,000 16____Change in sleeping habits 15____Change in number of family gatherings 15____Change in eating habits 13____Vacation 12____Christmas 11____Minor violations of lawScoring Your Test
_____________Your Total ScoreIf you are stressed out taking this test, add 10 points to your score.
Note: If there are events which took place in your life during the past year which are not listed, select a value from an event listed which approximates your experience closely.
Notice that 'positive' events (outstanding personal achievement, vacation, Christmas) can be as stressful as 'negative' ones.
Add up your Stress Scale points for the past twelve months. If it is above 250, you should be keenly alert for the early signs of OVERSTRESS. Even a level of 150 will OVERSTRESS ten percent of persons. For this reason, it is best to aim for a continuing stress load of below 150 on the Stress Scale.
Name:_______________________________________
Date: __________________
Active Release
Dr. Atencio is Certified Full Body in addition to Long Tract Nerve Entrapment. He has 12 years experience with Active Release Technique
Pain Control
Contact
1500 West 38th Street, Suite 38
Austin, TX 78731
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- Phone: 512-219-8999
- Fax: 512-219-7890
- Email Us
Spinal Decompression
Community Content
Rehabilitation
