Keeogo Pre-evaluation Questionnaire

Will you benefit from Keeogo™?

Thank you for your interest in Keeogo. This survey will allow you to understand how Keeogo works, and if it might be fit for you.

This survey should take 10 minutes to complete.

All information provided will be kept confidential and never released to any third party without your express written consent. This information is used to help assess if Keeogo can benefit you.

This questionnaire was designed by the B-TEMIA team

Contact:
B-Temia Inc.
4780 St-Félix Street, Suite 105
Saint-Augustin-De-Desmaures, Québec G3A 2J9
www.keeogo.com
Phone: (418) 653-1010
Email: sales@keeogo.com

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* 1. Keeogo™ is designed to fit those with a waistband of 26 to 42 inches, and a height of above 155cm. Do you fit these requirements?

Yes

No (please specify your waist size, height and other relevant information)

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* 2. Your contact information:

Full name

Adresse

Ville

Province

Postal code

Pays

E-mail

Numéro de téléphone

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* 3. Date of birth

day/month/year

Date

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* 4. How did you hear about Keeogo™?

Please specify

Keeogo Pre-evaluation Questionnaire

Will you benefit from Keeogo™?

Question Title

* 1. Keeogo™ is designed to fit those with a waistband of 26 to 42 inches, and a height of above 155cm. Do you fit these requirements?

Question Title

* 2. Your contact information:

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* 3. Date of birth

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* 4. How did you hear about Keeogo™?

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* 5. Do you feel you would benefit from added strength at the knee?