Survey

Always striving to improve your experience, any feedback, critique or praise you may have is always appreciated. You may submit this anonymously if desired. Checked fields are required.

Tell Us About Your Experience Survey

Your Gender *

Male Female

Was this your first visit? *

Yes No

How often do you receive bodywork? *

0-2 per year 3-6 per year 6-12 per year 12 or more per year

Do you know what type of bodywork you received on this visit? *

Swedish Deep Tissue ( WAC Sports Massage Cranio-Sacral Thermal Palms Relaxation Condition Specific Trigger Points Myofascial/Connective Tissue Other

Did you have any additional modalities or services on this visit? *

Hydrotherapy (Hot or Cold) Aromatherapy Acupressure Other

* Indicates required field

How did you hear about this site? *

Internet Search Advertisement Friend Another Health Professional Trainer Other

If Other please specify: *

What is your age? *

Less than 18 (was accompanied by parent or guardian) 18-25 26-35 36-50 Over 50 Prefer not to say

What is your household income? *

Less than $10,000 $10,001 - $25,000 $25,001 - $40,000 $40,001 - $70,000 $70,001 - $100,000 Greater than $100,000 Prefer not to say

Would you consider the price of your service to be:? *

Too Low Just Right Too High

Has there been a change in your condition? *

Much Better Somewhat Better About the Same Somewhat Worse Much Worse

If it thought it was a valuable part of your health and in your budget, how often would you get a massage? *

Everyday Once per week 2 to 3 times per week Once per month Less than once per month

Name *

First

Last

Email *

Phone Number *

Address *

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City

State

Zip Code

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