Date:-

Promoting health care

Survey Form
Name:- Mr./Ms. ____________________________
Age:- ____________________
Gender:- Male/ Female
Address:- ____________________________________
____________________________________________
Telephone:- ______________________
#1. Have you ever heard about physiotherapy? Yes No
#2. Have you ever visited Physiotherapist? Yes No
#3. Are you suffering with breathing problems? Yes No
#4. Are you suffering with Joint Pain? Yes No
#5. Are you satisfied with this camp? Yes No

Are you now well aware about physiotherapy? Yes No

“Help In Hands” www.helpinhands.co.in Email- helpinhands2017@gmail.com