Self-Assessment Form

Rubenstein Self-Assessment Form for Stress and Chronic Pain

The Rubenstein Method is best suited for people that are suffering from stress, anxiety, chronic pain, brain trauma or those that are looking to recover faster from acute injury or surgery. We know you have a lot of questions about stress and chronic pain and what solutions are directly availalbe for you. Please take a moment to fill out our self-assessment form below and one of our Certified Calibrationists will get back to you within 24 hours and let you know how or if we can help you specifically. There is no risk or obligation whatsoever and please remember that the Rubenstein Method comes with a money-back guarantee—you will feel better or you don’t pay.

Use the form below to provide the details of your stress and/or chronic pain. Please be as detailed as possible. If you have been diagnosed with something or if you are taking prescription medication or non-prescription medication please let us know as well.

We also have an online stress test that measures your predisposition for excess stress hormone production that you can take here.

First Name*
Last Name*
Date of Birth*
Where does your body feel tension, stress or pain? (check all that apply)*
How long have you been living with stress/pain in your body?*  Less Than 1 Year 1 to 3 Years 4 to 10 Years Over 10 Years
How would you rate the severity of your stress/pain on a scale of 0 to 10? (0= I am pain-free, 10 = take me to the hospital now)*
How would you rate the quality of your sleep on a scale of 0 to 10? (0= I don't sleep at all, 10= I sleep like a baby and wake up rested)*
What makes you feel better/worse?*
What would you say are the top 3 things that cause you to fell stressed?*
What makes you feel better/worse?*
What activities do you have trouble doing?*
What type of treatments have you tried?*
What activities do you have trouble doing?*
If other, please list those treatments here*
How many total appointments or treatment sessions do you think you've had in relation to your stress/pain?*
How much money do you think you've spent trying to get rid of or manage your stress/pain? Think of all the sessions you've had, medications you've taken*
Have you experiences cycles of relief in your stress/pain...if so what do you believe caused the relief?*
If you've had any injuries, concussions, accidents or surgeries please describe them here
Please list any diagnoses that you have received from any health professional(s)
What would it mean to you to be stress/pain free? How would it change your life? How would you feel? Feel free to be as descriptive as possible.
Please list any medications that you are taking*

Does your stress/pain keep you from work, social activities, family obligations?*