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2015
May
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What Subjects
What Subjects
Health Survey
0%
Exit Survey
Hello:
You are invited to participate in our survey about what health issues you may have and subjects interest you. In this survey, approximately people will be asked to complete a survey that asks questions about health information you would like to know more about]. It will take approximately 3 minutes to complete the questionnaire.
Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.
Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact the office by email at the email address specified below.
Thank you very much for your time and support. Please start with the survey now by clicking on the
Continue
button below.
I Agree
Do you suffer from any chronic health or pain condition/s?
Yes
No
Not Sure
Are you on any medication for the health condition?
Yes
No
How many different medications are you taking for your health condition/s ?
1-2
2-3
3-4
4-5
More than 5
What conditions do you take medication? (click as many as apply)
Thyroid
Type 2 Diabetes
Type 1 Diabetes
Fibromyalgia
High Cholesterol
Anxiety/Depression
Acid Reflux
IBS/IBD/Crohn's Disease
Cancer
Arthritis
MS
Insomnia
Peripheral Neuropathy
Pain
Heart/Cardiovascular Issues
Other
What health conditions are you afraid that you may suffer from in the future (Select all that apply)?
Cancer
Dementia
Alzheimer's Disease
Stroke
Cardio Vascular Disease
HIV/AIDS
Acid Reflux/GERD
IBS/IBD/GI Issues
MS
Diabetes
Amputations
Metabolic Syndrome
Lung Disease
Obesity
Thyroid Disorders
Autoimmune Disease
Arthritis
Other
Handling your health issues naturally will take commitment to diet, lifestyle, etc. On a scale of 1-10, 10 being YES, how would you rate your commitment to getting off your medication and doing whatever it takes to address your health naturally?
1
2
3
4
5
6
7
8
9
Woo-Hoo 10
Would you be willing to do whatever it takes to get off medication? (As long as it is safe)?
Yes
No
Maybe
Would you like to see information on my Facebook Page regarding your condition/s?
Yes
No
Maybe
Suggestions on information and health topics you would like to read on my Facebook Page:
Thank you for your time!
If you feel it would be appropriate, please share with your Facebook Friends. I know, not as fun as a Candy Crush request.
Please feel free to contact my office
regarding your chronic health issues.
404-477-1797
[email protected]
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