Welcome to BecomeHealthyNow.com's Health Survey. Questions marked with red * are required.
BecomeHealthyNow.com Health Condition Survey
Health Survey The health survey finds out about the state of your health. You may discover things about your health you did not know before. It is required that you answer every question on this survey. *1. If the number 10 was an ideal state of health with zero health complaints and 1 (one) was extremely poor health; how would you rate your current state of health choosing a number between one and ten? 1 2 3 4 5 6 7 8 9 10 *2. If you could change or improve anything about your health what would it be? *3. How long have you had this problem? Less than one month One to six months Six months to one year Several years As long as I can remember *4. Have you seen any doctors to help you with it? Yes No *5. What would you consider to be superior service a doctor could give? *6. What would you consider to be inferior service relating to a doctor or his or her office personnel? *7. What would the ideal doctor be like? *8. What could the ideal doctor say or promise that might interest you in receiving treatment from him or her? *9. What is your email address? *10. Your age? 18-25 26-35 36-50 51-75 > 75 *11. Have you registered on the site to purchase products in the store? Yes No *12. Do you receive our biweekly newsletter sent free of charge? Yes No *13. If you do not receive the biweekly newsletter, would you like to receive it? Yes No 14. Any other comments you would like to make?
1 2 3 4 5 6 7 8 9 10
Less than one month One to six months Six months to one year Several years As long as I can remember
Yes No
18-25 26-35 36-50 51-75 > 75
