Energy Feedback Form

Energy Feedback Form

Thank you for trying our product. Your feedback is valuable to us. This survey will take 10 minutes to complete. Your information will be kept confidential.
1. About you

Tell us more about yourself
1.1. Name*
1.2. Email*
1.3. Mobile Number

Country CodePhone Number
1.4. Age*
1.5. City and country of residence*
2. Before you used this product

Tell us about your condition
2.1. Do you take caffeine drinks every day such as coffee or tea?*

YesNo
2.1a. How many cups do you take a day? (standard “short” cup 227ml or 8 oz)*

1 cup a day2 to 3 cups a day4 to 5 cups a dayMore than 5 cups a day
2.2. Have you tried any energy booster drinks or supplement?*

NoYes, please specify:
2.2a Are they effective and do you still use them?*

Yes, they are effective and I am still using themYes, they are effective but I stopped using themNo, they are not effective and I stopped using them
2.2b. Why do you stop using them even though they are effective? *
2.3. What is your main reason(s) for taking energy boosting products? You may tick more than one reason.*

WorkStudyExerciseGamingOther, please specify
2.4. What do you want from taking energy boosting products?*

Improve energy levelImprove concentration levelImprove reaction timeOther, please specify
*Nearsighted (Myopia)*
Object near to you is clear, object far from you is blurred.

*Farsighted (Presbyopia)*
Object becomes clear when you move it further away.

*Sensitive to bright lights (Astigmatism)*
Blurred vision, difficulty adjusting to light changes/night vision.

*Dry eye*
Eye irritation, mucus, redness.

*Cataract*
Cloudy or foggy vision.

*Glaucoma*
Blurred vision, eye pain or redness.

*Age-Related Macular Degeneration (AMD)*
Distorted or partial loss of vision at centre.

*Diabetic Retinopathy*
Diabetic, blurred vision, faded colours, dark spots.
3. After you used this product

Tell us whether the energy booster powder helped
3.1. How did you consume this product?*

Take the powder directlyMix with waterOther, please specify:
3.2. Did you experience an energy boosting effect from this product?*

YesNo
3.2a. When did the effect start?*

ImmediatelyWithin 15 minsWithin 30 minsWithin 60 minsOther, please specify:
3.2b. How do you rate the overall effect of this product on scale of 1 to 5?*

1 - Very small effect2345 - Very big effect

3.2c_oth. Other symptoms (if any)
3.2d. How long did the effect last?*

Up to 1 hourUp to 3 hoursUp to 6 hoursLast the whole day
3.3. Did you experience any similar symptoms such as caffeine withdrawal/crash?*

YesNo
3.3a. What symptoms do you experience?*

TirednessUnable to concentrateHeadachesChange of moodOther, please specify:
Product Pricing

Now we would like you to think about Amelior's pricing
P1. At what price would you say Amelior is GOOD VALUE FOR MONEY?
*insert price in dollars & cents
P2. At what price would you say Amelior is EXPENSIVE BUT WORTH CONSIDERING?
*insert price in dollars & cents
*P2 Price should be higher than P1. GOOD FOR VALUE price. Kindly revise the price.
P3. At what price would you say Amelior is TOO EXPENSIVE TO CONSIDER?
*insert price in dollars & cents
*P3 price should be higher than P2. TOO EXPENSIVE TO CONSIDER price. Kindly revise the price.
P4. At what price would you say Amelior is TOO CHEAP TO BE OF VALUE?
*insert price in dollars & cents
*P4 price should be lower than P1. GOOD VALUE FOR MONEY price. Please revise the price.
4. How do you feel about this product?

Tell us what you think about the energy booster powder
4.1. How do you rate overall performance?*

PoorFairGoodVery goodExcellent
4.2. Will you recommend to family and friends?*

Definitely notProbably notSomewhat likelyProbably yesDefinitely yes
4.3. How likely are you to purchase again?*

Definitely notProbably notSomewhat likelyProbably yesDefinitely yes
4.4. Do you agree that this product is better than other energy boosting products?*

Completely disagreeDisagreeSomewhat agreeAgreeStrongly agree
4.5 Please rank the importance when looking out for an energy booster? Drag and drop the item from rank 1 (most important) to 6 (least important).*
4.6 Please share with us how you feel after using this product, and how we can improve.*
Thank You!

This is the end of the survey. Thank you.
Please tick if you allow us to use your information and feedback for marketing purpose.

Yes, you may use my feedback and only my initials for marketing purposes.Yes, you may contact me for more information.
Should be Empty:

	5 very big effect	4	3	2	1 very small effect	N/A
Improve energy
Improve concentration
Improve reaction time

Energy Feedback Form

1. About you

2. Before you used this product

3. After you used this product

Product Pricing

4. How do you feel about this product?

Thank You!