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Schedule a Free Anti Aging Assessment
Home
About Me
Services
Blog
Schedule a Free Anti Aging Assessment
Schedule a Free Sleep Assessment
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Phone number or Skype handle
*
Please list a few preferred appointment times. Free Anti Aging Assessments are 30 min.
*
Days of week and times of best availability.
Age
*
(an age range is OK, if you prefer)
What are your most important sleep concerns?
*
I have trouble falling asleep
I wake up and can't fall back to sleep
I don't feel like I sleep well. I wake up tired, not refreshed
I get up a lot to use the bathroom
I typically get less than 7 1/2 hours of sleep a night
I use sleep meds like Ambien
My work schedule interferes with getting a full night's sleep
Snoring
Travel /Jet lag
I think I may have sleep apnea
Which of the above is your #1 concern right now?
*
What have you already tried to address these issues? When was that? What were the results, if any?
*
It's OK to put "Nothing" or "NA" if you haven't tried anything yet!
Why is now the right time for you to address these issues?
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Common examples: recent changes or increased frustration around ability to sleep or quality of sleep; changes such as weight gain, trouble concentrating or remembering things, workout preformance; anti aging concerns.
What are the biggest obstacles to improving your sleep?
*
Do you think friends and family will be supportive of you making changes to improve your sleep?
Yes
No
If I am selected for a Free Sleep Assessment:
*
I have the necessary means to invest in my health and my future
I have the ability to get the necessary means to invest in my health and future
I have no financial means to invest in health and future
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