4) Indicate what your concerns are about your current conventional health care:

5 = Highest concern	1 = lowest concern		0 = no concern
_____ Drug side effects		_____ Expense
_____ Lack of doctor contact time		_____ Poor attitude of providers
_____ Failure to get positive results		_____ Lack of recourse for problems
_____ HMO/Insurance company interference		_____ Not Insured

_____ Other ___________________________________

5) Aspects of current conventional healthcare you like the most? Use back of page.

6) Mark your level of awareness or use of the following alternative health systems:

5 = Long time user		4 = A few treatments					3 = One treatment
2 = Know about it		1 = Heard of it					0 = Never heard of
_____ Homeopathy			_____ Bach Flower			_____ Shiatsu
_____ Ayurvedic			_____ Chiropractic			_____ Acupuncture
_____ Herbology			_____ Massage			_____ Vitamins/Nutritional

Others? _______________________________________________________

7) What encourages OR discourages you from trying any one alternative healthcare system?

5 = Very much	1 = Very little	0 = Not at all
_____ Friend's advice or experience			_____ Reading books about it
_____ Reading about it on the Internet			_____ Out-of-pocket cost
_____ Scientific reports on level of effectiveness			_____ Personal experience
_____ Reading magazines, newspapers			_____ Hearing about it on radio, TV

_____ Other_______________________________

8) If you had a bad experience with alternative healthcare please describe it on back.

9) How long one-way would you be willing to drive for a monthly consultation? ______ minutes

10) Where do you get your information and entertainment?

Radio:	Which stations?_______________________	Times? _______________
Newspapers:	Which ones? _________________________
Magazines:	Which ones? _________________________
Television:	Which stations? _______________________
	Programs? ___________________________
Other:	(Library, etc)? _________________________

11) If you would like me to contact you, you may enter the following personal information that will be maintained absolutely confidential:

Name ___________________________

Address ________________________________________________

City ______________ State ____ Zip _______________

Email and/or Phone____________________________________________

Health conditions of concern __________________________________

12) You may return this to: Roger Barr, POB 1427, North Fork, CA 93643-1427

Tel: (559) 877-7233; Thank you!

What is Homeopathy | Who Am I? | How I Work | Testimonials | About the Logo | Health Conditions
Overview | Contact | Take the Survey | Links & Resources | Tree Healing | Home 

©canhealyourself.com