Patient Intake Form

PATIENT INTAKE FORM

How did you hear about Coolief* Cooled Radiofrequency? Thank you for providing the information below regarding what led you to schedule today’s appointment to discuss Coolief* Cooled Radiofrequency. NO personal information is required. This questionnaire is designed purely to understand what brought you here today, and will only be used by the Coolief manufacturer to better understand how to communicate with patients.

Today’s Date: ___ /___ /____

Had you heard about Coolief Cooled Radiofrequency prior to making this appointment? h Yes h No (If no, no further information is required.)

Where did you first learn aboutC oolief? Please check as many boxes as apply. h Website

How did you find theC oolief website, www.myCoolief.com?

o Saw an ad for Coolief on the internet

o Searched for Coolief on the internet o Searched for chronic pain relief information on the internet o Heard the web address on a radio commercial o Saw the web address in a newspaper or magazine ad o Saw the link on my pain physician’s website o Other ______h Radio Ad Do you recall which station(s)? Check all that apply. o WBBM-AM News Radio o WGN 720-AM Talk, News and Sports Radio o WVAZ-FM V103 Urban Contemporary Music o WLS-AM Talk Radio o WLIT-FM 93.9MYfm Adult Contemporary Music Thank you for h Print Ad providing us with Do you recall which publication? this information. o Chicago Magazine We appreciate o Chicago Tribune your feedback. o Other ______h Referral I was referred by: o My General Practitioner o My Physical Therapist o Other doctor, please list their specialty:______o Family or Friend

o Another Coolief patient o Other ______