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  5. Health Survey
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Exit Survey
 
 
Do you think there is a NEED FOR A NEW CHIROPRACTOR in the neighbourhood?
 
Yes
 
No
 
 
 
Do you RECOMMEND THAT I OPEN a chiropractic office in this area?
 
Yes
 
No
 
 
 
Do you suffer from?
 
Headaches
 
Fatigue
 
Neck Pain
 
Shoulder Pain
 
Back Pain

 
 
 
Acute Pain?
 
Yes
 
No
 
 
 
Do any of your RELATIVES HAVE any of these HEALTH PROBLEMS?
 
Headaches
 
Fatigue
 
Neck Pain
 
Back Pain
 
Shoulder Pain
 
Chronic Lifestyle Diseases?
 
 
 
When I open my practice, would you like me to send you some literature pertaining to your health problem?
 
Yes
 
No
 
 
 
Do you know anything about Chiropractic and How it works?
 
Yes
 
No
 
 
 
Have you ever been to a chiropractor before?
 
Y
 
N
 
 
 
If you ever needed to go to a chiropractor (For main issue) what hours would you recommend their office be open?
   
 
 
 
When I open my office I will be giving health education classes, would it be ok to invite you to this class? There is no charge for your attendance.
 
Y
 
N