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1.

Thank You for Participating

For helping us compile data on the effectiveness of our products, we will be sending you a free gift of merchandise from our line. It will be shipped soon after the survey is processed. Please feel free to add your comments at the bottom of this form. We maintain privacy of all data and do not share names or contact information with anyone unless permission is given.
2.

Please Enter Your Contact Information Below

First Name*
 Last Name*
Company
Address*
City*
State*
Postal Code*
 Country*
Email*
Day Phone*
 Evening Phone
3.

Please Check the Appropriate Nature of Your Pain
Chronic
Acute
Triggered by Motion or Position
Activity Limiting
4.

Pain Level Before Treatment

Please rate your initial or typical pain on a scale of 1 to 10 where 10 is the most torturous pain you can imagine.
5.

Pain Location

Please list the location of the pain you are treating, e.g. neck, elbow, back, knee, foot, etc.
6.

20 Minute Pain Level

On a scale of 1 to 10, please rate your pain after the X-Celerel massage followed by a 15 minute TherapEze cold packing treatment.
7.

4 Hour Pain Level

On a scale of 1 to 10, please rate your pain 4 hours after the X-Celerel massage and TherapEze treatment.
8.

8 Hour Pain Level

On a scale of 1 to 10, please rate your pain 8 hours after the X-Celerel massage and TherapEze treatment.
9.

Lifestyle Improvement

If Appropriate, Was Your Activity Limitation Improved?
10.

If Recurrent, How Well Have Other Other Pain Remedies Worked For You

What other treatments have you tried for this pain and how well do they work? ------------------------------------ (e.g., Ibuprofen, pain level @1/2 hr after treatment => 2, pain @ 4 hr => 5, pain @ 8hr => 6)
Pain Level 30 Minutes After Taking Drug or Treatment
Pain Level 4 hr. After Taking Drug or Treatment
Pain Level 4 hr. After Taking Drug or Treatment
11.

Other Comments

Please enter any comments you would like to offer regarding issues not covered here.

12. CONTACT 

PLEASE FEEL FREE TO CONTACT US WITH QUESTIONS, COMMENTS OR TESTIMONIALS THROUGH OUR CONTACT PAGE BY CLICKING IN THE NAVIGATION BAR AT THE TOP OF THE PAGE. WE WOULD LOVE TO HEAR FROM YOU. THANK YOU.