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Active Family Chiropractic: Neuropathy Quiz
Please complete the survey below. The doctor looks forward to seeing you at the webinar!
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* Indicates required question
On a scale of 1 - 10, how much does neuropathy interfere with your quality of life?
Least interference
1
2
3
4
5
6
7
8
9
10
Highest impact
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Full Name
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
What interested you in this webinar?
*
I have neuropathy
I am looking for information for a loved one or a friend
I have to take medications because of my neuropathy and I don't want to anymore!
Required
"Other" interests for this webinar?
Your answer
What symptoms have you experienced as a result of your neuropathy?
*
Pain / Burning
Depression / Anxiety
Sedentary / Trouble Exercising
Weight Gain
Trouble Sleeping
Chronic Pain
Medication Causes Side Effects
Other:
What is your biggest struggle with implementing a healthy lifestyle?
*
Time
Energy
Stress
Lack of knowledge
Trouble sticking with changes
Lack of support
I want a doctor coach who...
*
knows my personal health goals and helps me achieve them.
teaches me what to do to be healthier.
provides support and motivation.
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