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Option 1
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Column 1
Row 1
Column 1
Row 1
Last Name
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Your answer
First Name
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Your answer
Middle Name
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
City
Your answer
State
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Your answer
Zip Code
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Your answer
Are you a:
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User of natural health
Practitioner of natural health
Both
History of Natural Health Use (check all that apply)
Herbal Remedies
Pro Biotics
Vitamins & Minerals
Traditional Chinese Medicine (acupuncture, acupressure, herbs)
Ayurveda
Breathing practices
Cranial Sacral Therapy
Guided Imagery
Healing Touch
Hypnosis
Homeopathy
Bach Flower Remedies
Massage Therapy
Meditation
Mindfulness
Naprapathy
Pilates
Progressive Relaxation
Qi Gong
Reflexology
Reiki
Spinal Manipulation
Tai Chi
Somatic Movement Therapy
Yoga
Feldenkrais
Alexander Technique
Sound Healing
Chiropractic
Doctor of Osteopathy
Naturopathic Doctor
Trager Psychophysical Integration
Core Synchronization
Chrystal Healing
Tarot or other card reading
Curandera
Shaman
Medicine Man/Woman
Sweat Lodge
Prayer
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