Acupuncture Program Exit Survey Kindly complete this form before the final acupuncture session in your program series. Member InformationFirst Name(Required)Last Name(Required)Date of Birth(Required)Preferred Email Address(Required)1. Age(Required)18 to 2425 to 3435 to 4445 to 5455 to 6465 or over2. Gender(Required) Male Female Non-binary Transgender Other 3. Home Zip Code(Required)4. Work Zip Code(Required)Health Background5. Please select areas of improvement since beginning the program.(Required) Chronic pain (e.g., back pain, neck pain) Stress or anxiety Insomnia or sleep disturbances Headaches or migraines Digestive issues (e.g., bloating, constipation) Fatigue or low energy Menstrual irregularities or menstrual pain Allergies or sinus issues Joint pain or arthritis Emotional imbalances (e.g., depression, irritability) None 6. Did you begin taking herbal supplements during the program?(Required) Yes No 7. If "Yes", please list the name(s) of the supplements:Dosage: For What Condition:Lifestyle8. I do muscle strengthening exercises 2 or more times a week.(Required) Yes No Sometimes 9. I do moderate-intensity aerobic exercise at least 150 minutes (2 hr and 30 minutes) per week.(Required) Yes No Sometimes 10. Please rate your current stress level with 0 being “Calm” and 10 being “Extremely stressed”.(Required)01234567891011. On a scale of 0 to 10, please rate your confidence in managing your stress, from 0 being “Not at all confident” to “Extremely confident.”(Required)01234567891012. On a scale of 0 to 10, how well do you understand the ways in which acupuncture supports your overall wellness, with 0 being "Not at all" and 10 being "Extremely well"?(Required)01234567891013. Please note any feedback or additional information you would like to share.14. I would recommend this program to friends or family.(Required) Yes No
