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1.
Contact information
Name
City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
Email Address
Phone Number
2.
How long have you had this bout of tennis elbow pain?
Less than 1 month
1 - 3 months
3 - 6 months
6 - 12 months
1 - 3 years
3+ years
Other (please specify)
3.
Have you had surgery for this pain on the involved elbow, wrist or hand?
Yes
No
4.
Have you ever had neck pain?
Yes
No
5.
If yes, how long ago was your last episode of neck pain?
6.
Have you ever experienced numbness, tingling or burning in your arm?
Yes
No
7.
Rate your elbow pain at its least amount (0-no pain - 10 severe pain)
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
8.
Rate your elbow pain at its greatest severity (0-no pain - 10 severe pain)
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
9.
Rate your difficulty opening a jar or turning a doorknob (0-no pain - 10 severe pain)
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
10.
Rate your difficulty carrying a grocery bag, briefcase / suitcase by the handle (0-no pain - 10 severe pain)
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
11.
Rate your difficulty with personal activities (cutting, cooking, dressing) (0-no pain - 10 severe pain)
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
12.
Rate your difficulty performing household/yard work (cleaning, vacuuming, mowing, trimming) (0-no pain - 10 severe pain)
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
13.
Rate your difficulty with recreational, gym or sporting activities (0-no pain - 10 severe pain)
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
14.
What do you think you did to create the elbow pain? (Check all that apply)
Racket sports (tennis, pickleball, racquetball)
Golf
DIY (hammer, screwdriver, painting, plumbing)
Household chores
Weight lifting
General exercise
Shoveling / raking
Carrying something heavy
Typing / use of mouse
Musical instrument
Not sure
Other (please specify)
15.
What is your profession?
Manufacturing (assembly line, warehouse, shipping/receiving)
Construction (painter, plumber, electrician, road)
Graphic Designer
Corporate (high computer usage)
Musician
Other (please specify)
16.
What solutions have you tried to cure tennis elbow? (Check all that apply)
Stop doing activity(s) that caused golfers' elbow
Over the counter medications (ibuprofen, acetaminophen, aspirin)
Prescription medications (anti-inflammatory, pain medications)
Ice/Heat
Self massage
Elbow sleeve
Elbow brace
Stretching
Percussion device
Physical therapy
Chiropractor
TENS and EMS
Acupuncture
Diagnostic tests (MRI, X-Ray)
Cortisone injection
Platelet-Rich Plasma (PRP)
Surgery
None of the above
Other (please specify)
17.
How have you researched /learned about tennis elbow? (check all that apply)
Basic Google / Bing search
Medical site research (WebMD, Mayo Clinic)
Amazon
YouTube
Social media
Non-medical friend
Other (please specify)
18.
The treatment program consists of using the Fiix Elbow device 10 min/day, 3x/week for 8 weeks. You must also complete simple stretching and strengthening exercises daily. Are you able to commit to this test period and follow the prescribed schedule?
Yes
No
19.
You will be asked to complete weekly surveys so we can follow your progress and assist with questions you may have. The surveys are for informational purposes only and your answers will remain private. Can you commit to completing these weekly surveys that take less than 5 minutes?
Yes
No
20.
How old are you?
Under 18
18 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65+
21.
What is your sex?
Male
Female
22.
Is there anything else you would like us to know about your tennis elbow pain?
