ALPHA-STIM

Check type of unit (check only one)

 Alpha-Stim® 100 microcurrent & cranial electrotherapy stimulator Alpha-Stim® SCS cranial electrotherapy stimulator Alpha-Stim® PPM microcurrent stimulator

Serial Number

Contact Information

Name

Check one:

 Practitioner purchasing for practice Patient purchasing for self

If practitioner, degree and specialty

Name of clinic or hospital where Alpha-Stim® is used

Address

City

State

Country

Postal Code

Phone

Fax

Email

Purchased From

Purchased City

Purchased Date

How did you learn about the Alpha-Stim® 100,Alpha-Stim® SCS or Alpha-Stim® PPM?

Questionnaire

The following optional, voluntary information would be appreciated and will help in our ongoing research. Please fill in after 30 days of use.

What is your diagnosis?

What is your age?

Sex? Male Female

How long have you been using the Alpha-Stim® technology?

How would you rate the results so far?

(check one box only): Worse (negative change) No change (0%) Slight improvement (1 to 24%) Fair improvement (25 to 49%) Moderate improvement (50 to 75%) Marked improvement (75 to 99%) Complete recovery (100%)

Would you consider Alpha-Stim® technology to be

(check all that apply) Safe Effective Ineffective