Patient Survey

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Which doctor prescribed the Zynex Device for you?*

Which Zynex Device was prescribed to you?*

Patient First Name*

Patient Last Name*

Date of Birth (mm/dd/yyyy)*

What area(s) of the body are you treating?

Question #1 - How many days per week do you use your Zynex Device?

Question #2A - How would you rate your pain before treating with the device on a scale of 1-10 (10 being the worst pain and 1 being no pain)?

Question #2B - How would you rate your pain after treating with the device on a scale of 1-10 (10 being the worst pain and 1 being no pain)?

Question #3 - Since using the device, have you reduced your usage of medication including pain killers, muscle relaxants, etc.?

Question #4 - How effective is the device with reducing your symptoms on a scale of 1-10 (10 being the best 1 being the worst)

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