Fill in the Health Survey
and receive A FREE GIFT WORTH $10!

Form must be filled in completely to receive your FREE GIFT.

E-Mail Address (Must be correct & working to receive your FREE GIFT)

Name

1. Are you concerned about the quality & cost of health care? Yes No

2. Over 50% of Americans are turning to alternative health care because of safety, effectiveness and low cost. Have you personally used alternative health care for any of these reasons? Yes No

3. Do you feel it is normal to get 3-4 colds or bouts of flu each year? Yes No

4. Some health care professionals feel that if your immune system is healthy, you should not routinely get colds and flu each year. Do you agree? Yes No

5. Do you believe that most life-threatening diseases are preventable? Yes No

6. Do you believe that most of these diseases are curable? Yes No

7. Do you believe with the American Cancer Society that many degenerative diseases can be prevented by good nutrition and antioxidants? Yes No

8. If you learned about a natural food supplement or topically applied product which claimed to help you overcome a problem of poor health, would you be interested in hearing more about it? Yes No

9. Do you believe that virtually all medically prescribed operations are necessary? Yes No

10. Do you believe that virtually all medically prescribed treatments are reliable? Yes No

11. Is there a member of your family with major health problems? Yes No

12. If so, please check the type of major problem. Cancer Cardiovascular Pulmonary Emotional Other(s) (please list)

13. Check if any of these is currently a health problem for you or your family: Hayfever Allergies Asthma Headaches PMS Joint Pain Chronic infection(s) Lack of Energy None

14. Would you be interested in learning of possible solutions to your health concerns in natural, alternative health care? Yes No

How did you hear of this survey? (Please be specific.)

Please make sure the information above is correct before submitting.
Your FREE GIFT WORTH $10 includes 3 audiotape transcripts and a Personal Health Checklist for your alternative health care education. Thank you!

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