Repeat Customer Survey: Following is a survey on how wearing a mask improves a person’s quality of life. Participation is voluntary and your identity will not be shared with anyone unless you give permission to use your name, e.g. Kara.

When we receive your response we will thank you with a 10% discount on your next order of up to $100 so up to a $10 discount. Adrien will keep a record of all responses. For discount read to the end.

You may copy the survey and e-mail or send by mail or fax. See contact information at the end of the survey.

Name:                                                                         Date:

Contact Information:   Phone:                                        E-mail:

State, Country                                            Age                          Male or Female   

Education: High School BA  MA PhD     MD RN Other

1. Check condition or conditions which prompted you to seek a mask?

A. Allergies

B. Asthma

C. Chronic Obstructive Pulmonary Disorder (COPD)

D. Emphysema

E. Chemical Sensitivity (aka MCS)

F. Alpha-One

G. Sarcoidosis

H. Chemotherapy

I. Heart condition

J. Other

2. What types of masks have you found improve your quality of life?

A. Silk or Organic Cotton Comfort mask

B. ACF Honeycomb Pollution Mask

C. Silk-lined Cold Weather Mask

3. Have you tried other brands of masks? Please indicate brands and experience.

4. Why have you chosen to use an I Can Breathe! Mask? Check or comment on following.

A. Adequate seal preventing offending irritants from entering your nose and lungs

B. Components of mask reduce exposure to irritating substances

C. Contents of mask are tolerated

D. Comfort

E. Adjustable ear loops

F. Other

5. In what circumstances have you found each mask most useful?

6. What is most difficult about wearing a mask?

A. Reactions of people who see you wearing a mask

B. Keeping track of mask, having it handy when needed.

C. Other

7. Did you decide to seek out a mask or was it recommended to you by a health care provider or friend?

8. Are you aware of any other non-invasive methods of reducing symptoms?

9. Any other remarks?

To receive 10% discount: If you order on Shop Site, post "RC-Survey" at shipping instructions. Or call 888-313-0123, leave your first and last name, phone number, and "RC-Survey."

Thank you for participating.

E-mail Adrien

Fax: 773-324-9315

Call Adrien 888-313-0123 for mailing address.

02/07/08 I Can Breathe! Inc.