Patient Survey

Please fill out survey and receive a free 15 min evaluation (a $60 value)

MHS will keep your information in strict confidence. This survey will be used only to help our MHS practitioners determine the causes of your health problems and see if we can help you to become healthier, happier and more balanced.

PURPOSE: To gain insight about any health concerns you have and to see if the practitioners at MHS can help you.

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

*Your name: Your age: *Home phone:
    Cell phone: Work phone:
Address: City: State/zip:   /
Occupation: How many hours do you work each week?

1. Check off any of the following symptoms you have experienced in the past six months:

2. Does this cause you to be:

3. Does this affect your work?

4. Does this affect your life?

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.

Would you like to get rid of the problem?

If your answer is Yes, there are several alternatives available to you. Please check the item most appropriate for you:

Would you like to schedule an appointment?

If you prefer, feel free to call us directly at 919-286-9595

We have morning, afternoon and evening times available on various days. Which time of day will work best for you?