Stress Survey

This survey has a purpose to find out if any health problems you may be having are due to stress.
All information is kept in strict confidence and we never give out or share your information.

Please fill out the following information and click the “Submit” button at the bottom of the form when done. Thank You!

Personal Detials
  1. (required)
  2. (required)
  3. (valid email required)
  4. (required)
1
  1. Check off any of the following symptoms you have experienced in the past 6 months
2
  1. Does this cause you to be
3
  1. Does this affect your work
4
  1. Does this affect your life
  2. If you checked any of the above items, your organs are probably not functioning as well as they could, and your energy is probably not flowing as smoothly as it could be.
ACUPUNCTURE and CHINESE HERBAL MEDICINE CAN HELP YOU
  1. Because they gently and naturally treat the body to remove the stress and imbalance that cause health problems.
  2. Would you like to get rid of the problem?
  3. If your answer is Yes, there are several alternatives available to you. Please check the item most appropriate for you:
Spam Protection
 

cforms contact form by delicious:days

 

 

Vita-Health Acupuncture and Wellness Center
12301 Taft St #200, Pembroke Pines, FL 33026
Phone: (954) 880-0090