$25 REBATE / FEEDBACK
FORM
Clients track their progress once per week for 4 weeks and once per
month to 3rd month
RE-SAVE THIS DOCUMENT EACH TIME YOU UPDATE IT
Please
return
by email only to; feedback@earthpulse.net
|
Last Name |
|
|
Purchase Date |
|
If DEVICE FAILS TO
PRODUCE
SATISFACTORY RESULTS, PLEASE RETURN THIS FORM
(COMPLETE TO 4TH WEEK -MINIMUM) TO RECEIVE
RETURN-AUTHORIZATION AND RETURNS INSTRUCTIONS
|
|
On a Scale of 1 -10
(10=BEST) |
|
Base-Line |
1 2
3 4 5
6 7 8
9 10 |
|
Prior to EarthPulse™
I’m sleeping |
(
) (
) (
) (
) (
) (
) (
) (
) (
) (
) |
|
My energy level is |
(
) (
) (
) (
) (
) (
) (
) (
) (
) (
) |
|
My physical performance level is |
(
) (
) (
) (
) (
) (
) (
) (
) (
) (
) |
|
My mental performance level is |
(
) (
) (
) (
) (
) (
) (
) (
) (
) (
) |
|
My resting-breath-hold (RBH) is |
In
seconds: |
|
My pain level is (10=worst) |
(
) (
) (
) ( ) ( ) ( ) ( ) ( ) ( ) ( ) |
|
My body-weight is |
__________ lbs. or
_________ kgs. |
|
|
1 2
3 4 5
6 7 8
9 10 |
|
Day 7 on EarthPulse™
I’m sleeping |
(
) (
) (
) (
) (
) (
) (
) (
) (
) (
) |
|
My energy level is |
(
) (
) (
) (
) (
) (
) (
) (
) (
) (
) |
|
My physical performance level is |
(
) (
) (
) (
) (
) (
) (
) ( ) ( ) ( ) |
|
My mental performance level is |
(
) (
) (
) (
) (
) (
) (
) (
) (
) (
) |
|
My resting-breath-hold (RBH) is |
In
seconds: |
|
My pain level is (10 = worst) |
(
) (
) (
) (
) (
) (
) (
) (
) (
) (
) |
|
My body-weight is |
__________ lbs. or
_________ kgs. |
|
Resting Breath Hold (RBH) almost never
fails to improve during first week. If RBH
failed to improve or got worse (even more rare), please read your RBH
instructions you received with this form and carefully redo the RBH
test. Usually a reduction can be tracked to a failure to oxygen load
properly (consistently with the past RBH). Comments: Please write as much as you would like in
the space below. The page will continue down as necessary. Please use
the device nightly during the first 90-day period (don’t loan it out!!!) to maximize statistical
probability and level of your success. Call for technical support if
you have any questions. Contact numbers are at end of this document.
Thank you! |