Stress Survey

Name *

First

Last

Phone Number *

Email *

Birthdate *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Which of these bothers your most? *

How long have you been bothered by this condition? *

Describe how it feels or affects you when it is at its worst: *

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 as smoothly as it could be.
ACUPUNCTURE AND CHINESE HERBALS MEDICINE CAN HELP YOU
Because they gently and naturally treat the body to remove the stress and imbalance that CAUSE health
problems

How did you hear about this site? *

Internet Search Advertisement Friend Other