Do you have any specific back or neck conditions like congenital problems, disc herniations, etc?

Yes   No

If Yes, please explain

Do you have any specific sleep problems?

Sleep apnea    Breathing problems    Excessive snoring   Other

If Other, please explain

What position do you sleep in generally?

On your back    On your side   Face down    Toss & turn

Do you generally like to sleep on

hard mattresses    soft mattresses

What is your main complaint about your existing bed?

Too hard    Too soft    Not supportive    Too old   Wake up with pain   Other

If Other, please explain

Do you wake up with pain or stiffness?

Back pain   Neck pain    Midback pain    Shoulder pain    Hip pain    Other

If Other, please explain

Do you wake up with numbness?

Arms / hands    Legs

Do you wake up with headaches?

Yes    No

Does your pain wake you up in the middle of the night?

Yes    No

How long have you been feeling this pain?

Recent    6 months    Over a year

Was the pain caused by any specific injury?

Yes    No

Do you use small or large pillows?

Small    Large

How tall are you?  feet, inches

How tall is your wife\husband\sleep-partner?feet, inches

What is your weight?   lbs

What is your wife's\husband's\sleep-partners weight? lbs

Have you already tried any TEMPUR-PEDIC mattresses?

Yes    No

Are you already considering one of the TEMPUR-PEDIC mattresses and why?

After evaluating your answers we will contact you as soon as possible.

Based on your answers one of our doctors may contact you with further questions. This can be done with either e-mail or by phone.

If you like one of our doctors to contact you by phone please provide

 Area CodePhone Number and what times and days are best for you:

Monday   Tuesday   Wednesday   Thursday   Friday

Mornings   Afternoons   Other

If Other, please explain

Your name:

First name    Middle initial    Last name

   Street address

   City

  State       ZIP code

   Your e-mail address

Your are now ready to send the info. Please click on the Submit button.

   Click on Submit                                      If you made a mistake to start all over!