Balanced You Participation Survey

Thank you for your interest in our program.

Please take this short survey to help us determine if the Balanced You program is right for you.

Name *

First

Last

Email *

Phone *

What is your age? *

Are you an existing patient at ERCA? *

Do you have any medical conditions? *

Check all that apply

If you checked "other" please list your medical condition(s)

Are you currently on any medications? *

If so do they need to be taken with food? *

Do you have any experience with fasting? *

Have you read either "Delay, Don’t Deny" by Gin Stephens or "The Obesity Code" by Dr. Jason Fung, M.D.? *

Do you want to try the program but don’t wish to fast? *

Can you commit to 2 treatments per week ( allow for 20-30 minutes)? *

Is there any thing else we should know about your medical history? *

Name