Health Assessment Survey

Question Title

* 1. What is the single biggest concern you have when it comes to your health?

Question Title

* 2. Is this affecting your life? Please explain how, where and with whom.

Question Title

* 3. Do you feel this health situation will be worse in 5 years?

Question Title

* 4. How Important is to you to handle this situation?

Extremely important

Very important

Somewhat important

Not so important

Not at all important

Question Title

* 5. How much hope do you still have that this health concern can be handled?

Extremely Hopeful

Very Hopeful

Somewhat Hopeful

Not so Hopeful

Not at all Hopeful

Question Title

* 6. If there is hope in handling it, how interested are you in finding out Natural Alternative solutions to help it?

Extremely interested

Very interested

Somewhat interested

Not so interested

Not at all interested

Question Title

* 7. After reviewing your answers above, the doctor will personally contact you to determine if what we do might be able to help you. Please provide your contact data below.

Name

Email Address

Phone Number