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Application
First Name
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Last Name
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Email Address
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What best describes your pain?
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What best describes your pain?
I've been dealing with pain for years
I had a recent injury or flare-up
I'm managing a chronic condition
I'm supporting someone with chronic pain
What's your biggest pain challenge right now?
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What's your biggest pain challenge right now?
Lower back pain
Neck and shoulder pain
Nerve Pain
Migraines or Chronic headaches
Post-injury or post-surgical pain that hasn't resolved
Pain that moves around or doesn't have a clear cause
Other
How long have you been struggling with this?
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How long have you been struggling with this?
A
Less than 6 months
B
6 months to a year
C
1 to 3 years
D
More than 3 years
What have you already tried to improve your sleep? (Select all that apply)
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What have you already tried to improve your sleep? (Select all that apply)
Physical therapy
Medication
Injections or Procedures
Therapy or counseling
Chiropractic/ Acupuncture
Meditation or mindfulness
Nothing yet
Do you currently use any sleep tracking tools?
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Do you currently use any sleep tracking tools?
Yes
I have in the past but not currently
No
Have you been diagnosed with a specific pain condition (such as fibromyalgia, chronic back pain, arthritis, migraines, nerve pain, etc.)?
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Have you been diagnosed with a specific pain condition (such as fibromyalgia, chronic back pain, arthritis, migraines, nerve pain, etc.)?
Yes, diagnosed and currently being treated
Yes, diagnosed but not currently being treated
No, I do not have a diagnosis for my pain or I have not seen a doctor about my pain
How is this pain affecting your daily life right now (work, relationships, sleep, mood, activity level)?
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What would change in your life if you slept well consistently?
(
This is the most important question on the form. Take a minute with it.
)
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Submit
