Sleep Assessment
Is your insomnia interfering with you everyday life?

You are not alone. Insomnia affects over 40 million people in the US.

Yes, we have a number of patients who use our all-natural products called Neurofeedback and Brain Tapping. It is drug-free, no risk and you have nothing to lose in trying this treatment.

Getting treatment for Insomnia

The following questions related to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of nights and days in the past month.

1. Fill out our FREE Sleep Questionnaire - answer the questions that will determine if you or your child are a good candidate for our treatment.
2. Book an appointment - schedule a FREE consultation.

We will email you with the results of your screening and send you a coupon to schedule a free consultation. Thank you for your time.

Feel free to reach us at SavingYourBrain.com with any questions or concerns.
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Email *
Full Name *
Contact Number *
Are you over 18 years of age? *
During the past month, when have you usually gone to bed? *
During the past month, how long in minutes has it taken you to full asleep *
When have you usually gotten up in the morning? *
How many hours of actual sleep do you usually get? *
During the past month, how often do you had trouble sleeping because you wake up in the middle of the night or early morning?
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During the past month, how often do you had trouble sleeping because you had to get up to go to the bathroom?
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During the past month, how often do you had trouble sleeping because you had trouble breathing comfortably?
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During the past month, how often do you had trouble sleeping because you cough or snore loudly?
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During the past month, how often do you had trouble sleeping because you feel too cold?
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During the past month, how often do you had trouble sleeping because you feel too hot?
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During the past month, how often do you had trouble sleeping because you have pain?
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During the past month, how often do you had trouble sleeping because you had dreams?
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During the past month, how often do you take medicine (prescribed or over-the-counter)?
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During the past month, how often do you have trouble staying awake while driving, eating meals or engaging in social activity?
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During the past month, how much of a problem has it been to have enthusiasm to get things done?
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Are you interested in scheduling a FREE 15-minute consult following this questionnaire with Dr. Kelly Miller to discuss your sleep issues?
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What is your preferred contact? *
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