AirFeet Wellness Survey

Ergonomic / Health / Wellness / Safety Assessment

Please complete each step carefully. Your answers help us provide the best recommendations.

Before You Start

Hello.
This is the 1st part of a 2 part survey and will provide us with your shoe size and how we can communicate with you.
It will also help us understand what areas of discomfort you are living and working with.

1) Move the BLUE DOT to the position that best describes your level of discomfort.

2) Check the Not Applicable (NA) box for Ailments that DO NOT effect you.

3) In the coming days, you will receive an email/sms to complete the the final part of the survey.

Please keep watch for it - check your Spam folder.

4) Watch the important Understand AIRfeet video at the bottom and look forward to The Best Weird You'll Ever Feel.

Accurately completing this survey will result in a free * pair of Airfeet Insoles - See bottom of page

Video

Critical Instructions for: - Wearing - Adjusting - Trimming - Fitting

Personal Information

Start Date:		Start Date is Required Date must be mm/dd/yyyy
Company:	Company is Required
Position within the Company			Position is Required
Years of Employment:		Years is required
Your Name:		Full Name is required
Age:	18-25 26-35 36-45 46-55 56-65 66+
Sex:	Male Female
Shoe Size:		Shoe size is required
Email Address:	Email Address Required Wrong Format
Confirm Email Address:	Email Addresses do not match
Phone to SMS:	Phone/SMS Required Wrong Format Must be: xxx-xxx-xxxx
Confirm Phone to SMS:	Phone do not match

FREE OFFER

As a special thanks for accurately completing this important survey and submiting it to AirFeet.
AirFeet will compliment you with a FREE pair of same SIZE AirFeet Insoles .

NOTE: The special offer is only valid for Employees

* This offer is limited in quantity to those who respond first.

What part of your workday is spent : (Total can be greater than 100)

Sitting	0%	25%	50%	75%	100%
Standing	0%	25%	50%	75%	100%
Walking	0%	25%	50%	75%	100%

		Low	Pain or Discomfort	High
		1 2 3 4 5 6 7 8 9 10
Flat Feet	NA
Leg Fatigue	NA
Foot Pain	NA
Ankle/Knee Pain	NA
Hip Pain	NA
Lower Back Pain	NA
Plantar Fasciitis	NA
Diabetic Foot Pain	NA
Poor Circulation	NA
Neuropathy	NA
Other	NA

		Low	Level of Effect	High
		1 2 3 4 5 6 7 8 9 10
Fatigue	NA
Loss of Energy	NA
General Tiredness	NA
Concentration	NA
Pain/Discomfort	NA

		Low	Distraction	High
		1 2 3 4 5 6 7 8 9 10
Fatigue	NA
Walking	NA
Standing	NA
Working	NA
Pain/Discomfort	NA