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Win A FREE book! Participate In Our Survey                        

Once you have used your entire container of SinusCleanser, please print, then complete the following questionnaire, then fax it to us (760-804-5704). We will send you a free book, IMMUNOPOWER, which explains how nutrition can fortify the immune system to lower the risk for infections and cancer.

Thank you for your assistance.

QUESTIONNAIRE FOR SINUS CLEANSER FORMULA             

Instructions: Please complete the following questions with an ink pen, then fax to AEN, Inc. at 760-804-5704

1) On a scale of 1 to 10 (10 being worst), how would you rate your sinus problems before using this product (often, makes headaches, need medication, etc.)
1‹2‹3‹4‹5‹6‹7‹8‹9‹10

2) After using up this bottle of SinusCleanser, how would you rate your current sinus condition?
1‹2‹3‹4‹5‹6‹7‹8‹9‹10

3) Are your sinus problems worse in (circle which is true for you)
SPRING? SUMMER? WINTER? FALL? AFTER RAIN?

4) Are you using medication (either prescription or over-the-counter) to get sinus relief?
YES NO, If yes, what medication(s) are you using?________________

5) Did your sinus problems begin after any particular event, such as moving to a new climate, or taking antibiotics, or getting pregnant, or after stressful situation, or?
YES NO If yes, what do you think triggered your sinus problems?___________________

6) Were you able to use the SinusCleanser product twice daily, as instructed?
YES NO If no, why not?_________________________________________

7) Were there any side effects from using the SinusCleanser formula? (such as stinging in the eyes, irritation in the nose, or?) YES NO
If Yes, what happened?__________________________________
Would this side effect prevent you from using this product?_______________________

8) Are there any suggestions you would make to improve this product?
(label, size, anything)
__________________________________________________________

9) What are you willing to pay for this product? (circle your answer)
up to $15 up to $20 up to $25 up to $35

10) What name would you suggest for this product? (circle one) | SINUS CLEANSER | SINUS PURGE | BREATHE EASY | SINUS SHOWER | SINUS FREEDOM | or _______________

11) Please write a line or two summarizing your experiences using Sinus Cleanser (i.e. really helped me breathe, didn¹t work, whatever)___________________________________________________

Please fax your completed form to 760-804-5704 Thank you for your cooperation. Please print your name and address clearly to receive your free copy of IMMUNOPOWER. This form will be your shipping label.

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