BioBack Experience Evaluation Form

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Thank you for sharing information regarding your experience(s) with the BioBack. Your feedback will help us to continue our efforts to deliver a superior product in order to provide pain relief and help improve the quality of life for low back pain sufferers. Please rate your experience with the BioBack no sooner than after having tried the BioBack at least three times over the course of at least one week.

Your name? *

Age

Gender *

Female

Male

Prefer not to say

Are you currently suffering from or experiencing back pain *

Yes

No / Sporadic Flare Ups

On a scale of 1 (no pain) to 10 (extreme pain) rate your back pain when present: *

No Pain

Extreme and Constant Pain

How long have you had back pain?

Does your back pain limit you from performing any activity or activities

Yes

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Did the BioBack fit you perfectly right out of the package? *

Yes

If not, did the instructions / information provided clearly explain how to resize / fit the BioBack? *

Yes

Could be improved (please add comment at end of survey)

Did the instructions / information provided clearly explain how to apply, wear and use the BioBack? *

Yes

Could be improved (please add comments at end of survey)

Rate your experience with BioBack for following: *

1. No Benefit

2. Some Benefit

3. Moderate Benefit

4. Good Benefit

5. Incredible Benefit / Relief / Comfort

6. Not Applicable

Pain Relief

Improved Mobility (able to resume an activity)

Improved Posture

Reduced Need for Pain Medication

Pain Prevention

Comfort

How often did you wear the BioBack? *

Daily

As needed for Pain Relief

As needed for Pain Prevention

As Needed for Posture Improvement / Support

Did not utilize BioBack after first experience

Required

If you continued to use BioBack, on average how long did you wear the BioBack per use? *

Less than 1 Hour

1 - 3 Hours

4 - 6 Hours

7 - 9 Hours

10 Hours or more

Rate your overall experience with the BioBack *

Poor (No or limited benefit)

Excellent (Incredible Benefit or Relief)

Would you recommend the BioBack to others? *

Yes

What do you think is an appropriate Retail Price (what would you be willing to pay) for the BioBack? *

Comment(s) or Testimonial Regarding BioBack Use:

If you provided comments or a testimonial, may we have your permission to reproduce or publicly use your first name and last initial with your evaluation feedback? *

Yes

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