MODEL NO.	(on bottom of monitor or on plastic label of wrist units)
PURCHASE DATE	(mm/dd/yy)
FIRST NAME
LAST NAME
ADDRESS
CITY
STATE:	ZIP
TELEPHONE	AGE
EMAIL
Optional Questions:
1) Is this product for you or did you receive it as a gift?
2) Why did you buy this particular product? In other words, what attracted you to this particular product? (For example: Product features, Attractiveness of packaging, Price)
3) How did you learn about this product?
4) Is there anything we should change about the unit or the packaging of the unit? If yes, please describe.
5) Please check any of the following you are concerned about: Allergies Blood Cell Count Cholesterol Salt Arthritis Body Fat Hearing Stress Asthma Calories Pulse Weight Blood Sugars
6) What is your annual household income? Less than $40,000 $100,000 to $150,000 $40,000 to $75,000 $150,000 to $200,000 $75,000 to $100,000 Above $200,000
7) At what location did you buy this monitor? Store City State
8) What was the price of the unit?