 |
|
|
 |
|
|
 |
|
|
|
|
 |
|
Why Jordan's: Sleep Lab Prescription
Presciption Worksheet
Before you visit the Sleep Lab, print this page or download the checklist below and answer the following questions. Our Sleep Technicians can then suggest the right sleep surface for your needs.
Download Checklist (PDF) 
| 1. | Have you been in the Sleep Lab before? ___Yes ___No
If yes, which sleep technician helped you? _______________ |
| 2. | Have you established your comfort level? ___Yes ___No
If yes, is it______Firm ______Cushion Firm ______Plush? |
| 3. |
Who is the bed for? ___Adult ___Child ___Guest |
| 4. |
How old is the current set? ________ |
| 5. |
What size mattress do you currently own?
___Twin ___Twin XL ___Full ___Full XL
___Queen ___King ___California King |
| 6. |
What size would you like to purchase?
___Twin ___Twin XL ___Full ___Full XL
___Queen ___King ___California King
|
| | 7. | What type of sleep surface have you slept on?
_____Coil (innerspring) _____Foam _____Water _____Air |
| 8. |
What type of bed do you have?
___Headboard and Footboard
___Headboard only
___Frame only |
| 9. |
If you look under your bed, how many slats do you see? _______
How many legs? _______ |
| 10. |
What is the measurement from the floor to the top of your bed frame
or rail? _______ |
| 11. |
How thick is your mattress set? __________ |
| 12. |
Is your bed/mattress set currently ________Too high? _____Too Low? |
| 13. |
Do you currently have any back pain or medical concerns?
_____No _____Yes, Please describe __________________________ |
| 14. |
What position do you sleep in?
_____Back _____Stomach _____Side |
| 15. |
How soon do you need your new sleep surface? ______________________ |
| 16. |
How old are your pillows? ____________________ |
| 17. |
What type of pillows do you currently use?
_____Down _____Fiber Filled _____Latex _____Shredded Latex |
| 18. |
How many pillows do you sleep with? ____________________ |
|
Your Name _______________________ Delivery Address _________________ |
|
|
|
|
 |
|
|
