The Minute Survey!

Thank you for taking the survey.
Information provided in this survey is confidential.
After completing survey, click "Submit" at bottom of page.

 Select any health problems
 in survey you experience.

Headaches        Migraines              Neck Pain
Back Pain         Low Back Pain       Disc Problems
Arm Pain          Hand Pain              Shoulder Pain
Hip Pain            Leg Pain                Foot Pain
Arthritis            Bursitis                  Chronic Pain
Fibromyalgia     Muscle Spasms      Sprain or Strain
Numbness or Tingling in Hands or Arm
Numbness or Tingling in Feet or Legs

Sports related injury
Automobile Injury
Work related Injury

I would like literature pertaining to my health problem
I would like to receive your monthly newsletter
Please invite me to your FREE health classes

First Name:
Last Name:
Zip Code: (5 digits)
Cell Phone (+ area code):
Other Phone (+ area code):
 Phone books used:

Yellow Book   Dex   First Choice AT&T Yellow Pages
What insurance
provider do you use?

Medicare           Blue Cross/Blue Shield
Aetna                United Health Care
Cigna                Humana
No Insurance
Other Insurance (specify in comment box)

What do you enjoy to read? Chicago Tribune        Chicago Sun Times
Daily Herald               Northwest Herald
Arlington Almanac     Our Family
Pioneer Press            Red Eye Express
Chicago Magazine     Northshore Magazine
Other (please specify in comment box)


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Please select "Submit" to send the survey.
Thank You for taking the Minute Survey!

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