Worksheet



PLEASE CLICK AREAS THAT CONCERN YOU.

HOW LONG HAVE YOU
BEEN HAVING THESE CONCERNS?


HOW MUCH PAIN ARE
YOU EXPERIENCING?



HELP US UNDERSTAND YOUR LIFESTYLE & ACTIVITIES

DAILY ACTIVITIES

             

SHOE STYLES


WORK ACTIVITIES


HOW DID YOU HEAR ABOUT US?

AGE
GROUPS

WHAT ARE YOUR CONCERNS TODAY?

             

Good Feet recommends that you consult with your Doctor if you have diabetes, arthritis, or have had recent surgeries (past 6 months) on your lower
limbs or back prior to purchasing arch supports.
   
(Initial)

*First Name: *Last Name:

*Address: Suite, Apt, Bldg.
*City: *State/Province:

*Country: *Zip/Postal Code:
Phone Number: Phone Type:

Occupation: *Email:
Date:
5/7/2014 8:17:10 PM

THANK YOU FOR HELPING US PERSONALIZE YOUR ARCH SUPPORT FITTING!


EMPLOYEE USE ONLY


EXERCISER

MAINTAINER

RELAXER

YOUTH


CONSULTANT

DATE

* STORE LOCATION

   I don't see my store