HWF Research Project - Baseline Survey

Dear Research Participant,

We are delighted you have agreed to participate in this important Healer Within Foundation research project! The purpose of the research is to demonstrate the dissemination and benefits of a replicable Tai Chi and Qigong program for the general public.

To begin, please complete this FIRST questionnaire below. Then, each week you will answer a few questions both before and after class. We’ll also ask you to complete an exit survey after the six or eight weeks class cycle.

Your responses will remain anonymous. We sincerely thank you for your time and valuable feedback!

Question Title

* 1. Your Information:

Practice Leader Name (Your Teacher or Group Leader)

State (If virtual, the state your Practice Leader is in)

Your Email Address (this is your unique ID for research purposes only)

Question Title

* 2. Have you previously taken a class or regularly practiced Qigong or Tai Chi? (Please select one)

Yes

Question Title

* 3. What are the main reasons for your medical/doctor visits? (Please check all that apply)

Skin Disorders

Joint Pain and Osteoarthritis

Back Problems

High Cholesterol

Upper Respiratory Problems (Not Including Asthma)

Anxiety/Bipolar Disorder/Depression

High Blood Pressure

Chronic Neurological Disorders

Headaches/Migraines

Diabetes

Other Health Issue(s)

Question Title

* 4. Do you suffer from pain on a regular basis?

Yes