MedFit Sleep Solutions

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Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Numberoptional
Please enter a valid phone number.
4
I am age * years old.
I am height in feet * feet and inches * inches tall.
I weigh approximately weight in lbs. * lbs.
5
What type of pain do you experience most frequently?* This field is required.
Neck Pain
Shoulder Pain
Upper Back Pain
Lower Back Pain
Hip Pain
Other (please describe)
No Pain
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If you picked "Other" above, please describe.* This field is required.Type N/A if nothing
7
How would you rate your pain level when waking up in the morning?* This field is required.
No Pain
Mild Discomfort
Moderate Pain
Severe Pain
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What is your primary sleep position?* This field is required.
Side Sleeper
Back Sleeper
Stomach Sleeper
Combination of the above
9
Do you often wake up with numbness, tingling, or discomfort in your arms or hands?* This field is required.
YESNO
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If you chose "YES" please specify* This field is required.Type N/A if no
11
How would you describe your mattress firmness?* This field is required.
Soft
Medium
Firm
Adjustable
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Do you have any diagnosed conditions that affect your sleep, such as sleep apnea, TMD, Ehlers-Danlos Syndrome, or any other sleep condition?* This field is required.If yes, please specify
YESNO
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If you picked "YES" please specify * This field is required.Type N/A if no
14
What type of pillow do you currently use?* This field is required.
Memory Foam
Down/Feather
Latex
Gel-infused
Other (please specify)
15
If you chose "OTHER" above please specify* This field is required.Type N/A if nothing
16
How satisfied are you with your current pillow?* This field is required.
Very Satisfied
Somewhat Satisfied
Neutral
Somewhat Dissatisfied
Very Dissatisfied
17
Are you looking for specific features in a pillow?* This field is required.
Cooling Properties
Contour Support
Hypoallergenic Materials
Adjustable Firmness
Cervical/Neck Support
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How Do You Like Your Pillow Firmness?
1
2
3
4
5
Soft
FIrm
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How Tall Do You Like Your Pillow?
1
2
3
4
5
Small
Tall
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Would you like to receive a free consultation about your pillow needs and chronic pain management?* This field is required.
YESNO
21
AppointmentIf you are in the DFW area, we do FREE pillow fittings. Schedule your appointment today!
22
Who Referred you?* This field is required.Please select the provider or individual that referred you. Choose N/A if none apply.
Please Select
Please Select
N/A
Brian Landers
Steve Burr (Adrian Chiropractic)
@heatherconradd
@raisingtheconraffam
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How would you like to be contacted for your custom pillow recommendation?* This field is required.
Email
Phone
Text
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