BIOflex^®-Magnetic Pads

We are interested in your experience with BIOflex^® Magnetic Pads. Therefore we kindly ask you to fill in this questionnaire and return it to us. We guarantee our strictest confidence in assessing the returned forms; immediately upon receipt, the forms will be separated from the e-mail-addresses.

We require the following information for statistical purposes only:

What is your profession?

How long have you been working in this profession?

years

What is your age?

10 - 20 21 - 30 31 - 40 41 - 50 51 - 60 More than 60

Are you

male female

How did you learn about BIOflex®-Magnetic Pads?

Book / Books TV Recommendation Other

1) Which of our products have you used?

Disk (Ø 40 x 1,5) mm Rectangular (83 x 53 x 1,5) mm Disk (Ø 75 x 1,5) mm Rectangular (120 x 50 x 1,5) mm Disk (Ø 90 x 1,5) mm Rectangular (150 x 90 x 1,5) mm

2) What ailments have you treated with the Pad?

Neck pains Poor vascularity of the skin Pain of the thoracic spinal column Varicose veins Pain of the lumbar spinal column Sprains Pain of the hip Phantom pains Pain in the knee Scar pains Menstruation pain   Other

3) How long have you been suffering from these pains?

For some years For some months For some weeks For some days

4) Have you received medical / non-medical / other treatment?

Yes Drugs / ointments / injections Physiotherapy Acupunkture Other No

5) Did it, or does it still, restrict your reaction capabilities at work or in road traffic?

Yes   No

6) Have you experienced an improvement of your condition after the application BIOflex®-Magnetic Pads?

considerable improvement Magnetic Pad alone moderate improvement Magnetic Pad and other treatment no improvement   (see Item 4)

7) When did the improvement occur?

After some minutes After some hours After some days Not at all

8) Were you able to

Omit the other treatment referred to under Item 4? Reduce

9) Where have you applied the BIOflex®- Magnetic Pad (s)?

How many hours per day?

10) Have you had allergic reactions, such as itching and/or blisters, during the application of BIOflex®-Magnetic Pads?

Yes   No

11) If you have answered question 10 with "yes", were these irritations in the area of the Magnetic Pad or in the area of the fixing material?

Below the manetic Pad In an adjacent area Below the fixing material

12) Start of treatment: - -   End of treatment: - -

Notes / Comments: