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.



(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?     Yes No Not Sure

4. Do you wake up with pain in the morning?     Yes No

5. If yes, where is that pain located?
 R hip L hip R shoulder L shoulder Neck Back

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 Top Firm Innerspring Air Memory Foam Latex Don't Know

8. About how old is your mattress?     0-2 Years 3-5 Years 5-8 Years 9-12 Years 13+ Years

9. Do you take anything to help you sleep?
 Alcohol Sleep Medication (prescribed) Pain Medication Natural Herbs (melatonin, chamomile, etc.)

10. Do you wake up refreshed in the morning?     Yes No

11. Do you understand the role sleep plays in healing and wellness?     Yes No

12. Have you been diagnosed by your doctor with any of the following conditions:
 Herniated or Bulging Disk Nerve Damage Fibromyalgia Arthritis MD Restless Leg Syndrome Acid Reflux Neck Injury Hip or Shoulder Injury

13. What type of pillow do you currently use?
 Regular Pillow Foam Down/Feather Latex Air Water Don't Know

14. How happy are you with your pillow?     Very Just OK Not At All

15. Do you or your significant other     Snore Suffer From Allergies Get Headaches At Night

16. Do you have trouble falling asleep?     Yes No

17. Do you have trouble staying asleep?     Yes No

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



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