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* 1. What topics would you like to discuss during this program? (Check all that apply)

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* 2. Would you attend a weekly or monthly program? (Check all that apply).

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* 3. What day of the week would be preferable to meet on? (Check all that apply)

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* 4. What time of day would be preferable to meet on? (Check all that apply)

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* 5. What would you like to get out of these programs? (Be as descriptive as possible about any treatments, symptoms, or lifestyle choices you would like to have discussed)

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* 6. Have you had any of the following? (Check all that apply)

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* 7. Please fill out the following to get additional information on these programs:

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