Questionnaire
1.Method of purchase: (check all that apply)
�Medicare �Insurance �Medicaid �Other
2.This product was purchased for use by: (check one) �Self �Parent �Spouse �Other
3.This product was purchased for use at: �Home �Facility �Other
4.I purchased a
5.Who referred you to
�Relative �Dealer/Provider �Other
�Advertisement (circle one): TV, Radio, Magazine, Newspaper �No Referral
6.What additional features, if any, would you like to see on this product?
7.Would you like to receive information about
�Yes �No
If yes, please list any condition(s) here and we will send you information by email and/or regular mail about any available
8.Would you like to receive updated information via email or regular mail about
9.What would you like to see on the
10.Would you like to be part of future surveys for
11.User’s year of birth:_______________
If at any time you wish not to receive future mailings from us, please contact us at GF Health Products, Inc., 2935 Northeast Parkway, Atlanta, GA 30360,
To find more information about our products, visit www.grahamfield.com
