Bair Medical Spa

Patient Questionnaire

How did you hear about us? Have you visited our web site?
Internet
Radio
ABQ the Magazine
Sage Magazine
Posh
Paso Tiempo
Boomer
Phone Books
Referral from Another Doctor 		YesNo
What days do you listen to the radio? Please list what radio stations:
Weekedays
Weekends
What days of the week do you
read the paper? 		What is your
favorite newspaper?
Everyday
Weekdays
Saturdays
Sundays
What time of day do you
watch TV most? 		What is your favorite
station for late news?
6-9 AM
9-Noon
Noon-3 PM
3-6 PM
6-9 PM
9-11 PM
What is your
educational level? 		What is your gender?
GED
High School Diploma
Trade School
Some College
College Grad
Post Graduate 		Female Male
What age group are you? Which household income level
best describes you?
What is your zip code?
101 Hospital Loop NE, 111, Albuquerque, NM 87109. 505-881-1532. Info@BairMedicalSpa.com