Final Results Survey Name* First Last Date MM slash DD slash YYYY Phone*Email* At which Revitalize Health location are you a patient?* Sugar Land The Woodlands Did you follow the dietary directions during the program?* Yes No If no, please explain why:Did you follow the supplement directions during the program?* Yes No If no, please explain why:Did you follow the exercise instructions during the program?* Yes No If no, please explain why:What results did you see during your program?*How many medications were you on?*How many medications were you able to eliminate?*Did you accomplish your goals?* Yes No Explain why/how:*Do you feel prepared to move forward on your own?* Yes No Explain why/how:Are there any areas or interests in the program for which would you like more information?*How was the program material for the diet?*How was the program material for exercise?*How was your experience in our office? What suggestions or changes would you make?*How was your experience with the video program? What suggestions or changes would you make?*Do you feel that the program was a good value for your investment?* Yes No Explain why:*Did we meet or exceed or expectations?* Yes No Explain how/why:*Would you refer a friend or family member to this program?* Yes No Names and phone numbers of referrals: I give permission to Revitalize Health to use any or all of the data in this results survey, in my written testimony, or other program material for marketing purposes, studies, and/or research data.
