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ModPodPillows Prototype Questionnaire I

ModPodPillows – Prototype Application

This short questionnaire helps us understand your sleep and whether the ModPodPillow prototype may be suitable for you.

This is not a medical assessment.

Section & - About You

Age Range

*

Age Range

A

18 - 30

B

31 - 45

C

46 - 60

D

61+

Height (approx.)

*

Height (approx.)

A

under 160cm

B

160- 170cm

C

171 - 180cm

D

181 - 190cm

E

Over 190

F

Weight Range (optional)

Do you sleep alone?

*

Do you sleep alone?

A

Yes

B

No

C

Every Day Pain and Other Symptoms

Do you suffer from any of the following during the day? (tick as many as apply to you)

*

Do you suffer from any of the following during the day? (tick as many as apply to you)

Neck pain

Shoulder pain

Back pain

Hip pain

Knee pain

Ankle pain

Dead fingers

Dead arm

Dead leg

Acid reflux

Do you suffer from any of the following after or during sleep? (tick as many as apply to you)

*

Do you suffer from any of the following after or during sleep? (tick as many as apply to you)

Neck pain

Shoulder pain

Back pain

Hip pain

Knee pain

Ankle pain

Dead fingers

Dead arm

Dead leg

Acid Reflux

Are your pain symptoms affected by sleep?

*

Are your pain symptoms affected by sleep?

Alleviated

Aggravated

No change

Has anyone commented on your sleep (snoring, restlessness)?

*

Has anyone commented on your sleep (snoring, restlessness)?

A

Yes

B

No

C

Occasionally

Section 2: Your Current Sleep

Overall sleep quality

*

Overall sleep quality

A

Very Poor

B

Poor

C

Average

D

Good

E

Very Good

Average sleep per night

*

Average sleep per night

A

Under 5 hours

B

5 - 6 hpours

C

6 - 7 hours

D

7 - 8 hours

E

Over 8 hours

How often do you wake uo in the night?

*

How often do you wake uo in the night?

A

Rarely

B

1 - 2 times

C

3 - 4 times

D

Frequently

Do you feel rested on waking?

*

Do you feel rested on waking?

A

Rarely

B

Sometimes

C

Usually

D

Almost always

Section 3: Sleeping Position & Movement

Usual sleeping position when falling asleep

*

Usual sleeping position when falling asleep

A

Left side

B

Right side

C

Back

D

Front head right

E

Front head left

F

Changes night to night

Position you usually wake up in

*

Position you usually wake up in

A

Same as I fell asleep

B

Different position

C

Varies

Movement during the night

*

Movement during the night

A

Very little

B

Some

C

A lot / restless

Do you use more than one pillow?

*

Do you use more than one pillow?

A

Yes

B

Sometimes

C

No

If yes why? (tick as many as apply)

*

If yes why? (tick as many as apply)

Comfort

Neck support

To prop myself up

To stop rolling

Habit

Other

Snoring & Breathing

Have you been told that you snore?

*

Have you been told that you snore?

A

Yes

B

No

C

Unsure

If yes, how would you describe it?

*

If yes, how would you describe it?

A

Occasional

B

Regular

C

Loud / disruptive

Have you ever been diagnosed with sleep apnoea?

*

Have you ever been diagnosed with sleep apnoea?

A

Yes

B

No

C

Unsure

Are you currently using any sleep-related treatment?

*

Are you currently using any sleep-related treatment?

CPAP

Mouth guard

Sleep app / tracker

None

Prefer not to say

ModPodPillows is not intended to diagnose or treat sleep conditions.

Pillows and Past Experience

Pillows tried in the last 2 years

*

Pillows tried in the last 2 years

A

1 - 2

B

3 - 5

C

6 - 10

D

Lost count

Typical spend on pillows

*

Typical spend on pillows

A

Under £50

B

£50 - £100

C

£100 - £250

D

Over £250

What leads you to change your pillow?

*

What leads you to change your pillow?

Too soft

Too firm

Loses shape

Neck discomfort

Not helping

Other

What level of support does your current pillow offer?

*

What level of support does your current pillow offer?

A

Soft

B

Medium

C

Firm

D

Memory foam

What level of support does your current mattress offer you?

*

What level of support does your current mattress offer you?

A

Soft

B

Medium

C

Firm

D

Memory foam

Motivation & Suitability

Why are you interested in this prototype?

*

Why are you interested in this prototype?

Improve sleep quality

Alleviate discomfort / Pain

Reduce snoring

Comfort / support

Curious to try something different

Other

What would success look like to you?

*

What would success look like to you?

Fewer night wakings

Feeling lore rested

Less snoring (as reported by others)

Greater comfort

Reduce pain

Reduce other symptoms

Not sure yet

Feedback & Participation

Are you happy to test an early-stage prototype and provide honest feedback?

*

Are you happy to test an early-stage prototype and provide honest feedback?

A

Yes

Untitled multiple choice field

A

No

*

B

Yes

Would you be willing to:

*

Would you be willing to:

Complete a feedback survey

Provide a written testimonial

Share a short comment on social media

May we use your anonymised feedback in product development and marketing?

*

May we use your anonymised feedback in product development and marketing?

A

Yes

B

No

Any additional comments? (you can also tell us why you particularly would like to be accepted for this trial)

*

First and Last Name:

*

Phone Number:

*

Email:

*

Final Confirmation

I understand this is a prototype product and not a finished retail item, and that my feedback helps shape future versions.

*

I understand this is a prototype product and not a finished retail item, and that my feedback helps shape future versions.

A

Yes