A local chiropractic clinic wants to establish a relationship with our organization where they bring their mobile clinic on-site to offer chiropractic care for our group. The purpose of this survey is to find out if that service would be used, and how many people are interested.

Who is filling out this form?

What company do you work for, and what is your role there?

Do you currently, or have you ever been to a chiropractor?

Yes, I go to one currently

Yes, I have been to one, but am not currently going

No, I've never been to one but am interested in trying it

No, I've never been to one, and am not interested in trying it

If our organization were to bring a chiropractor on-site, would you use that service?

Yes

No

If you answered yes to the last question, how often would you use that service?

Rarely, or as needed

Once per month

Every other week

Once per week

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