:: Stretching Survey Form

Please fill out the following survey to request a sheet of excellent Stretches from Anderson Ergonomics Consulting.
(Items marked with an * denote required fields.)

First Name*:		Last Name*:
Email Address*:
City:
Country:
Phone Number:
Fax Number:
Company:
Position:
Which of these workplace settings do you work in?*	Office	Industrial
Would you like us to contact you with information about our services?*	Yes	No

Please check off which part of your body is causing you problems:

Head			Neck
Eyes
Left Shoulder			Right Shoulder
Upper Back			Lower Back
Left Elbow			Right Elbow
Left Forearm			Right Forearm
Left Wrist			Right Wrist
Left Hand, Fingers, Thumb			Right Hand, Fingers, Thumb
Left Hip			Right Hip
LeftLeg			Right Leg
Left Knee			Right Knee
Left Calf			Right Calf
Left Foot			Right Foot