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BecomeHealthyNow.com Needs & Wants Survey
Needs & Wants Survey Tell Us What You Want! By completing this survey, you are entitled to a $10 credit on the purchase of any items in the store. There is no cash value to this promotional offer. It is required that you answer every question. Make sure you enter a valid email address. *1. Why are you visiting this web site? *2. Is there a health concern that you would like to handle? Yes No *3. If you answered yes to question number two, what health concern do you want to handle? (If you answered no enter N/A). *4. How much money do you ususally spend on health care per year? (out-of-pocket expense; not paid by insurance) < $100 $101- $500 $501 - $1000 $1001 - $2000 $2001 - $5000 $5001 - $10,000 > $10,000 *5. What do you want from a healthcare website such as this one? *6. Would you be interested in speaking with a doctor regarding your health concerns? *7. Would you want to buy supplements and/or services from a website? Yes No *8. If you answered yes to question number 7, what supplements and/or services would you most be interesed in? (If you answered no type N/A) *9. If you answered no to question number 7, why not? (If you answered yes, enter N/A). *10. If there was a structured program that offered phone consultations at a reasonable cost with a licensed doctor or health care practitioner for the purpose of guiding you on a health regimen, would you be interested? Yes No *11. If you answered yes to question number 10, how much would you expect to pay for such a service? If you answered no to question 10 enter N/A *12. On a scale of 1 to 10 with one being the easiest and 10 being the most difficult, rate how difficult you feel it is to find a good doctor. 1 2 3 4 5 6 7 8 9 10 *13. If we could refer you to a local doctor who would provide (in our opinion) good care, would you be interested? Why or why not? *14. Any other comments or questions you have? *15. What is your email? *16. What is your age? < 18 19 - 25 26 - 35 36 - 50 51 - 65 > 65
Yes No
< $100 $101- $500 $501 - $1000 $1001 - $2000 $2001 - $5000 $5001 - $10,000 > $10,000
1 2 3 4 5 6 7 8 9 10
< 18 19 - 25 26 - 35 36 - 50 51 - 65 > 65
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