UpperStorey Care Clinic

Helping to Heal Naturally

Questionnaire

*How did you find us?
Google
Other search engine
Yellow pages
Friend
other
*What therapy are you interested in?
Bioresonance
Hypnotherapy
Holistic Therapies
EFT
Combination of all ticked
*What would you like us to help you with?
Smoking
Health & Wellbeing
Allergies
Pain/Illness
Weight Loss
Anxiety/Stress/Panic Attacks
Confidence/Self Esteem
Other

What age group are you?
18 - 25
26 - 35
36 - 45
46 - 55
over 55
If you want to become a non smoker, How long have you smoked?
under 5 years
5 - 10 years
10 - 20 years
over 20 years
How many cigarettes do you smoke per day?
10 - 15
15 - 20
20 - 30
30 - 40
40 +
*Would you like us to send you further details?
Yes
No
I will contact you to make an appointment
{ParagraphsSidebar}