How would you rate your overall sleep with 10 being fantastic (8 hours a night) and 1 being poor (I do not sleep unless I take strong medication and even then I struggle)*12345678910How many hours of sleep would you average per night?Do you often wake during the night?*YesNoHow often do you wake up during the night?*123More than 3 timesDo you suffer from any of the following Back pain Joint pain Neck pain Arthritic pain Nerve pain Sciatica Arthritis Diabetes Respiratory Problems such as breathing trouble, emphysema or asthma Poor circulation including cramps and cold feet Heart Attack High/Low Blood pressure Do you have a Pacemaker or Defibrillator Oedema Swelling in the legs Stroke Restless legs Bruising Thyroid problems Headaches Stress and/or Anxiety Hiatus hernia Reflux Sleep Apnea Fatigue Other Please describe what other ailments you are experiencingIs there anything else not listed that causes you pain or discomfort?What type of arthritis do you have?* Rheumatoid Osteoarthritis Not Sure How do your rate you back pain from a scale of 1-10*123456789101 being not too painful and 10 being unbearable.How do your rate you joint pain from a scale of 1-10*123456789101 being not too painful and 10 being unbearable.How do your rate you neck pain from a scale of 1-10*123456789101 being not too painful and 10 being unbearable.How do your rate you nerve pain from a scale of 1-10*123456789101 being not too painful and 10 being unbearable.How do your rate you Sciatic pain from a scale of 1-10*123456789101 being not too painful and 10 being unbearable.How do your rate you respiratory issues from a scale of 1-10*123456789101 being a little shortness of breath and 10 being server breathing issue. How do your rate your sciatica pain from a scale of 1-10*123456789101 being not too painful and 10 being unbearable.How do your circulation from a scale of 1-10*123456789101 being nothing notable and 10 very poor. Do you take blood pressure medication for high or low blood pressure?* High Low Do you type of diabetics do you have?* Type 1 Type 2 Are you:* Single Widowed Partnered Prefer not to say Does your partner often experience broken sleep or suffer from any of the ailments listed above?YesNoPartner's First NamePartner's AgeAre you currently:*PensionerDepartment of Veteran AffairSelf-funded retireeEmployedUnemployedAre you currently working: Full Time Part Time Casual What is your currently/ Last occupation*Complete your details:* First Last Postcode*Phone NumberEmail Based on your survey answers, we would love to share some information with you on how to improve your sleep. Yes, I authorise Revitalife to contact me by (and including but not limited to) phone, mail and/or electronic messaging regarding promotional offers and products for an indefinite period or until I opt out.*YesNoThank you for taking the time to participate in our Health and Sleep Assessment. Is there anything else you'd like to share with us at this time?CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
