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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 Graham-Field product because:
�Price �Features (list features) �Other
5. Who referred you to Graham-Field products? (check all that apply)
�Doctor �Therapist �Friend
�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 Graham-Field products
that may be available for a particular medical condition?
�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
Graham-Field products that may help treat, care for or manage such
condition(s):
8. Would you like to receive updated information via email or regular
mail about Graham-Field home medical products? �Yes �No
9. What would you like to see on the Graham-Field website?
10. Would you like to be part of future surveys for Graham-Field
products? �Yes �No
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, 800-347-5678
To find more information about our products, visit www.grahamfield.com