Bed And Sleep Assessment Form - Wellbeing Chiropractic
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1Bed and Sleep Assessment Form
Patient Name:______________________________________________________
Date:___________
How old is your current mattress?______________________
How old is your current pillow?________________________
Where did you get your current mattress from?________________________________________________
What describes your current mattress? (Select all applicable)
‡ Extra Firm
‡ Firm
‡ Intermediate
‡ Soft
‡ Latex
‡ Spring ‡
Foam ‡
Water
‡ Viscoelastic
‡ Other
What do you like about your current mattress? ________________________________________________
What don’t you like about your current mattress?______________________________________________
Approximately how much do you weigh?________________
In what position do you sleep?
‡ Side
‡ Stomach
‡ Back
‡ Combination
Do you experience any of the following?
1.
Sleeping with your hand under your pillow?
‡ Never ‡ Seldom
‡ Usually
‡ Always
2.
Broken sleep
‡ Never ‡ Seldom
‡ Usually
‡ Always
3.
Waking up with stiffness/soreness in any of the following areas?
‡ Neck
‡ Mid-back
‡ Low back
‡ Shoulders
‡ Knees
‡ Other ________________
4.
Waking up with numbness, pins and needles? If so, where ________________________________
‡ Never ‡ Seldom
‡ Usually
‡ Always
5.
Trouble falling asleep
‡ Never ‡ Seldom
‡ Usually
‡ Always
6.
Constant tossing and turning
‡ Never ‡ Seldom
‡ Usually
‡ Always
7.
Sleep apnea
‡ No
‡ Yes
How would you rate the quality of your sleep?
‡ Excellent
‡ Good ‡ Average
‡ Poor
Do you feel refreshed and rested when you wake up?
‡ Never ‡ Seldom
‡ Usually
‡ Always
How often is your sleep disturbed by your partners movement?
‡ Never ‡ Seldom
‡ Usually
‡ Always
‡ N/A
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Parent category: Medical