For the following list of services, please select the response that best describes your level of interest:

	1. An on-staff Medical Doctor.
	Not Interested Indifferent Slightly Interested Moderately Interested Very Interested

	2. A Certified Physical Therapist on staff.
	Not Interested Indifferent Slightly Interested Moderately Interested Very Interested

	3. An on-staff Nutritionist.
	Not Interested Indifferent Slightly Interested Moderately Interested Very Interested

	4. An on-staff Naturopathic Doctor.
	Not Interested Indifferent Slightly Interested Moderately Interested Very Interested

	5. A pain management program.
	Not Interested Indifferent Slightly Interested Moderately Interested Very Interested

	6. An Orthopaedic Doctor on staff.
	Not Interested Indifferent Slightly Interested Moderately Interested Very Interested

	Please select YES or NO as your response to the following questions.

	7. I am currently under the care of a Chiropractic Physician.
	YesNo

	8. I am currently under the care of a Medical Doctor.
	YesNo

	9. I am currently receiving physical therapy.
	YesNo