ReBuilder™ Evaluation Kit

 

 

Name :____________________________________________Date:______________

 

Street Address: __________________________________________________________

 

City: __________________________________    State: ____   Zip: _____________

 

Home Phone: (_____)  ________--________________________

 

E-Mail Address: ___________________________________________________ 

 

 ______________________________________________________________________

 

 

Thank you for agreeing to participate in our evaluation of the ReBuilder.  When you have finished this evaluation, please return it to us as soon as possible in the postage pre-paid envelope provided.

 

This package includes your agreement to participate and 3 forms to record your experience with the ReBuilder for ten days and the envelope with which to return the 3 forms to us.

 

Form number one will note your relative levels of pain (if pain is one of your symptoms) on a scale of 1 to 10 with ten being the highest level of discomfort, just before you use the ReBuilder, and right after you use the ReBuilder.  (If pain is not one of your symptoms please mark N/A on the form.)

 

Form number two will note your relative levels of numbness and/or tingling (if numbness is one of your symptoms)  on a scale of 1 to 10 with ten being the highest level of numbness and/or tingling, just before you use the ReBuilder, and right after you use the ReBuilder.  (If pain is not one of your symptoms please mark N/A on the form.)

 

If using the ReBuilder once per day for 30 minutes, you will only use the first ten spaces.

 

 If you choose to use the ReBuilder twice a day rather than once per day, then you will fill up all 20 spaces on the forms.

 

Form three is a questionnaire that notes any overall improvement in your quality of life, if you feel that your symptoms have improved, if you plan to continue using the ReBuilder after this initial evaluation, and if you would recommend the ReBuilder to others who have symptoms similar to yours and feel free to add other interesting observations.

Form number one

Pain levels

Form number two

Numbness and tingling levels

Form Number three

Overall quality of life evaluation and comments

1.  Do you feel that your symptoms improved with the ReBuilder?        Yes____          No____

2.  Do you feel that the ReBuilder was easy to use?                                           Yes____          No____

3.  Would you recommend the ReBuilder to others?                                          Yes____          No____

4.  Would you voluntarily continue to use the ReBuilder?                                   Yes___            No____

5.  Do you feel that your quality of life was improved?                           Yes____          No____

6.  Had you tried prescription pain meds before using the ReBuilder?     Yes___            No____

7.  Which treatment was better- the pain meds or the ReBuilder?                       ReBuilder____Meds____

8.  Were you taking pain meds with the ReBuilder?                                           Yes____          No____

9. If so, which prescription medicines and how many milligrams per day?  ____________________________________

Please provide any comments you would like to record relative to your particular symptoms, situation, medical history, etc., please do so below:

__________________________________                                        ____________________

Name                                                                                       Date

ReBuilder Evaluation Study

Enrollment Form

Please enroll me in your ReBuilder Evaluation study.  I will use the ReBuilder as instructed for 10 days, fill out and return the three forms in the envelope provided within 5 days of my last treatment.

I have been informed that my results will be tabulated, evaluated, and reported relative to the results only, and that no personal information will be revealed or available to anyone other than the directors of this study.

I understand that this evaluation study is informal and is to be used to help determine if this modality shows promise to help manage the peripheral neuropathy symptoms that sometimes accompany treatment with chemotherapy.  I have not been promised any particular clinical outcome.

I have been informed that the ReBuilder is non-invasive.

I do not have any implanted electrical devices such as a pacemaker or insulin pump.

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Printed name                                                                                                    Date

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Signature