Please take a moment to complete the following survey to help us serve you better.
Thank you for taking the time to complete this survey! Your input is important to us.
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1. What is your primary reason for seeking acupuncture treatment? Check all that apply:
Stress relief
Insomnia
Pain
Infertility, impotence
Immune system support
Gynecological disorders
Gastrointestinal disorders
Addictions
Other
If you selected other, please specify:
2. What are your treatment goals / objectives? Check all that apply:
Relief from symptoms
Long-term health benefits
Feeling of well-being
Alternative to prescription drugs
Other
If you selected other, please specify:
3. What is your preferred location for receiving treatment?
Near work
Near home
Specify zip code:
4. What is (are) your preferred treatment day(s)?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
5. What is your preferred time of day?
7 am - 10 am
10 am - 12 noon
12 noon - 2 pm
2 pm - 4 pm
4 pm - 6 pm
6 pm - 8 pm
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