Questionnaire

Since Dr. Elitzur is interested to know the needs of the buyers will you please fill in the following form and hit the "Submit" button below
(If you forget to hit submit, no message will be sent out to us.)

Questionaire

First Name: Last Name: (or last initial)
(Impression will be added to the site with only your first name)

Sex: Male Female Age:

Email Address:

Please, indicate your expectations from the Relaxation CD:
(place an "X" in the boxes that apply to you)

To be more relaxed?
To sleep better at night?
To cope better with stress?
To cope better with anxiety
To cope better with a physical ailment?


If you feel anxious, please indicate your major symptoms:

If you suffer from ailment, please share with us:

Please, describe your Impression of this Site & Recorded Relaxation Sessions:

If you have any Additional Comments Please write here:


How did you hear of this site? Please select one... Recommendation Google Yahoo Craigslist Other Search Engine Our Website Don't Know Other


(Your IP address will be recorded to control spam)