Thank you for giving us the opportunity to help you improve the quality of your sleep. We have over 15 years of experience helping people resolve their sleep problems and would like to help you, too. Please complete the following form, providing as much detail as possible. No salesman will call and your information will not be shared with others. One of our Sleep Specialists will evaluate your condition and provide you with information or help you understand your condition and suggest solutions that have proven effective in reducing sleep related pain. You can choose to receive this information by email or by telephone. The choice is yours. It is our pleasure to share the results of our work with medical specialists in all areas of pain and sleep with you as well as information about the role the right mattress and pillow can play in providing relief from pain and more deep, healing sleep.

YOUR NAME: DATE:

EMAIL: PHONE:

(no salesperson will call, and your information will not be shared)

1. On a scale of 1–10, with 10 being the BEST, about how well do you sleep?

2. About how many hours per night do you sleep on average? hours

3. Do you toss and turn frequently?    YesNoNot Sure

4. Do you wake up with pain in the morning?    YesNo

5. If yes, where is that pain located?
R hipL hipR shoulderL shoulderNeckBack
Other:

6. How severe would you rate that pain in each area on a scale of 1 – 10, with 10 being Greatest Amount of Pain?

7. What type of mattress do you sleep on?
Pillow TopFirm InnerspringAirMemory FoamLatexDon't Know

8. About how old is your mattress?    0-2 Years3-5 Years5-8 Years9-12 Years13+ Years

9. Do you take anything to help you sleep?
AlcoholSleep Medication (prescribed)Pain MedicationNatural Herbs (melatonin, chamomile, etc.)
Other:

10. Do you wake up refreshed in the morning?    YesNo

11. Do you understand the role sleep plays in healing and wellness?    YesNo

12. Have you been diagnosed by your doctor with any of the following conditions:
Herniated or Bulging DiskNerve DamageFibromyalgiaArthritisMDRestless Leg SyndromeAcid RefluxNeck InjuryHip or Shoulder Injury

13. What type of pillow do you currently use?
Regular PillowFoamDown/FeatherLatexAirWaterDon't Know

14. How happy are you with your pillow?    VeryJust OKNot At All

15. Do you or your significant other    SnoreSuffer From AllergiesGet Headaches At Night

16. Do you have trouble falling asleep?    YesNo

17. Do you have trouble staying asleep?    YesNo

18. How would you prefer to receive our analysis of your sleep condition and recommendations that might help you reduce your pain levels?    Via PhoneVia Email (make sure we have your e-mail address)

 

 

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