How
tall are you? *User 1:
Select Height
Under 5ft
5-ft. 1-in.
5-ft. 2-in.
5-ft. 3-in.
5-ft. 4-in.
5-ft. 5-in.
5-ft. 6-in.
5-ft. 7-in.
5-ft. 8-in.
5-ft. 9-in.
5-ft. 10-in.
5-ft. 11-in.
Over 6-ft +
User 2:
Select Height
Under 5ft
5-ft. 1-in.
5-ft. 2-in.
5-ft. 3-in.
5-ft. 4-in.
5-ft. 5-in.
5-ft. 6-in.
5-ft. 7-in.
5-ft. 8-in.
5-ft. 9-in.
5-ft. 10-in.
5-ft. 11-in.
Over 6-ft +
What
is your Age(s): User 1:
Choose One
10 - 15 yrs.
15 - 19 yrs.
20 - 24 yrs.
25 - 29 yrs.
30 - 34 yrs.
35 - 39 yrs.
40 - 44 yrs.
45 - 49 yrs.
50 - 54 yrs.
55 - 59 yrs.
60 - 64 yrs.
65 - 69 yrs.
70 - 74 yrs.
75 - 79 yrs.
80 - 84 yrs.
85 - 89 yrs.
90 - 94 yrs.
95 - 100 yrs.
100 + yrs.
User 2:
Choose One
10 - 15 yrs.
15 - 19 yrs.
20 - 24 yrs.
25 - 29 yrs.
30 - 34 yrs.
35 - 39 yrs.
40 - 44 yrs.
45 - 49 yrs.
50 - 54 yrs.
55 - 59 yrs.
60 - 64 yrs.
65 - 69 yrs.
70 - 74 yrs.
75 - 79 yrs.
80 - 84 yrs.
85 - 89 yrs.
90 - 94 yrs.
95 - 100 yrs.
100 + yrs.
What is your weight?
User 1:
Choose One
less than 80
80-100
100-120
120-150
150-180
180-210
210-240
240-265
over 265
User 2:
Choose One
less than 80
80-100
100-120
120-150
150-180
180-210
210-240
240-265
over 265
How
would you rate your physical condition,
User 1:
Choose One
1
2
3
4
5
6
7
8
9
10
Choose One
1
2
3
4
5
6
7
8
9
10
What
is most important to you in a massage chair?
Choose One
Price
Warranty
Looks
Durability
Strength of massage
Bells and whistles
Describe what you
think the perfect massage would do for you?
What areas of
your body would you say needs the most massage attention on
a regular basis?
Choose One
Neck
Shoulders
Mid Back
Lower Back
Seat and Thighs
Calves
Feet
How often, if
ever, do you see a massage therapist or chiropractor?
Choose One
once a week
twice a month
once a month
twice a year
Once a year
Never
Do
you or the other user(s) have any medical issues or injuries
which the massage chair would be used to help, if so please
describe.
Have
you tried a massage chair before, if so, which one
Choose One
Panasonic
Premier Health
ijoy
Interactive
Inada
Human Touch
Osim
Ive never tried one
Where
did you try this massage chair?
Choose One
Brookstone
Sharper Image
Relax The Back
Vending chair
in the mall
Another store
What
did you like the most about this massage chair?
What did this chair
not do for you?
What is your price
range*
Choose One
1000-2000
2000-4000+
Would you
be interested in financing?
Choose One
Yes
No
What
is your time frame for purchase?
Choose One
I'm just window shopping
Within the next
2 months
Within the next month
Within the next
week or 2
Right away
Full Name:*
Email:*
Address1:
Address2:
City,
State, Zip* , Telephone:*
