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If your require more assistance there is an on-line questionnaire consult which provides you with the opportunity to forward your details directly to me. I will analyse the questionnaire and provide you with individual advice regarding the management of your waking symptoms.

On-line consultation- A fee of $45.00 AU will be charged for this service.
Your credit card details will be required for payment upon completion of the questionnaire either by phoning in your information or fill in the downloadable form & fax back.
Billing :: Phone in your Credit Cards Details :: Or Fill in form details and Fax back

Please complete this on-line consultation regarding your sleep habits, general health and fitness, pillow type and waking symptoms. The responses from this questionnaire will be analysed to determine the risk factors which you have for the presence of waking neck pain, stiffness, headache and aching between the shoulder blades or in the arm and appropriate advice given regarding the management of these factors to decrease the likelihood of waking symptoms.

2nd Stage - Questionnaire
Contact Details - * Denotes required fields
*Name  

*Surname

 
*Address  

*City

 

*Email

 
Postcode

*Phone

 
State

Facsimile

*Country  

Mobile

          
A blank response will be considered to be a no response.
1. Name
2. Date of birth
3. Gender
4. Height
5. Weight
6. Clothes size:    shirt

jeans/trousers

7. Occupation
8. Briefly describe the types of work duties and the approximate percentage of your work day you spend on each duty.

8.

9. Briefly describe the types of sport and recreational activities in which you participate and how often in a usual week.

9.


Neck Pain - Check/tick if yes applies :: Not checked = a no response.
  10. In a usual week do you wake in the morning at least once with a sore or painful neck?
11. On how many mornings in the last week have you woken with neck pain?
12. How long did the pain or soreness in your neck last?
  13. In a usual week do you go to sleep at least once with a sore or painful neck?

 

14. If yes is the soreness and pain still present in the morning?
15. Briefly describe the area of your neck pain upon waking.

15.


Neck Stiffness - Check/tick if yes applies :: Not checked = a no response.
  16. In a usual week do you wake in the morning at least once with a stiff neck?
17. On how many mornings in the last week have you woken with neck stiffness?

18. How long did the stiffness in your neck last?
  19. In a usual week do you go to sleep at least once with a stiff neck?
  20. If yes is the stiffness still present in the morning?
21. Briefly describe the area of your neck stiffness on waking.

 21.

 

Headache - Check/tick if yes applies :: Not checked = a no response.
22. In a usual week do you wake in the morning at least once with a headache?
23. On how many mornings in the last week have you woken with a headache?
24. How long did the headache last?
25. In a usual week do you go to sleep at least once with a headache?
26. If yes is the headache still present in the morning?
27. Briefly describe the area of your headache on waking.
27.

Aching between the shoulder blades and in the arm
28. In a usual week do you wake in the morning at least once with aching between your shoulder blades or in your arm?
29. On how many mornings in the last week have you woken with aching between your shoulder blades or in your arm?
30. How long did the aching between your shoulder blades or in your arm last?
31. In a usual week do you go to sleep at least once with aching between your shoulder blades or in your arm?
32. If yes is the aching between your shoulder blades or in your arm still present in the morning?
33. Have you injured your arm or shoulder recently?
34. If yes, please briefly describe the area of injury upon waking.
34.

35. Briefly describe the area of your waking shoulder blade pain and/or arm ache.

35.

General Health - 36. Please tick if you have any of the following
Rheumatoid arthritis?
Fibromyalgia?
Diabetes?
Elevated blood sugar level?
High blood pressure?
Sleep apnoea?
Cardiac or heart problems?
Osteoporosis?
Asthma or breathing difficulties?
Digestive complaints?
Anxiety disorder?
Depression?
Osteoarthritis?

General Health Questions continued:
37. Have you been diagnosed with any form of cancer?
38. Do you have any medical condition which you believe regularly decreases your sleep quality?
38. If yes please describe the condition.
38.
39. Do you snore?
40. Does your snoring disturb your bed partner?
41. Do you smoke?
42. If yes, how many cigarettes per day?
43. Do you grind your teeth at night?
44. Has your Doctor advised you to take medication for any condition?
45. If yes, could you please list the medication.
45.
46. In a usual week do you drink alcohol in the evening?
47. If yes how many drinks would you have per night?
48. Do you drink caffeine beverages before bed?
Neck Injury History
49. Have you ever had an injury or accident involving your neck?
50. If yes please describe the injury or accident?
50.
51. Did your waking symptoms commence after this injury?
52. Have you had Xrays/CAT Scan/MRI of your neck?
  53. What did these investigations show?
53.
54. Have you had treatment of your neck or the spine between your shoulder blades?
55. What type of treatment have you had?
55.
56. How did this treatment help?
56.
57. Do you have exercises that you perform for your neck?
Sleep Quality
58. In a usual week how would you rate your sleep quality?
59. Do you suffer from daytime sleepiness?
60. Do you nap during the day?
61. Are you concerned about the amount of time it takes you to fall to sleep?
62. How long do you sleep each night?
62a. Is your sleep regularly disrupted for some reason other than a medical condition?
62a. If yes for what reason.
62a.
63. How many times do you wake during the night?

Sleep Position

64. In what position do you mostly sleep?

64.a

What type of mattress do you sleep on?
 
Your pillow/s
65. How many pillows do you use to support your head and neck as you sleep?
66. What shape is your pillow?
67. What is your pillow filled with or made of?
68. Approximately how long have you been sleeping on your current pillow?
69. Do you have to adjust or change the position of your pillow during the night?

70. If you need to adjust or change the shape or position of your pillow during the night please describe what you do
and why you need to change the pillow?

70.
71. Please rate the comfort of your pillow?
 
72. Is there anything else you would like to tell me about your waking symptoms, general health or your pillow?
72.

Click to submit your online Questionnaire which will be addressed once payment has been processed, Thank you

Billing:: Thank you for taking the time to fill out this questionnaire. Your responses will be analysed and advice forwarded to you regarding the management of your waking symptoms. If further information is required you will be contacted by e-mail. Once payment has been processed, you should expect a reply within four working days.

Billing :: Phone in your Credit Cards Details :: Or Fill in form and Fax back to us


Susan J Gordon Pty Ltd 2005