Holistic Health Treatment Selection Survey 🧘♀️
Help us understand your preferences for holistic health approaches.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Health Concern
*
Please Select
Stress
Pain
Digestive Issues
Sleep Disorders
Energy Levels
Other
Preferred Treatment Type
*
Herbal Therapy
Acupuncture
Massage Therapy
Meditation
Nutritional Counseling
Other
Brief Description of Your Symptoms or Goals
Previous Holistic Treatments Used
Please Select
Herbal Supplements
Acupuncture
Massage
Meditation
Nutrition Plans
None
Likelihood to Try New Techniques
*
Unlikely
1
2
3
4
Very Likely
5
1 is Unlikely, 5 is Very Likely
Are you currently under medical supervision?
*
Yes
No
Preferred Treatment Schedule (e.g., Weekly, Monthly)
First Name
Last Name
Consent to participate in holistic treatment program and data collection for treatment effectiveness purposes.
*
1
I agree
Submit
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