Pacifica Compounding Pharmacy

Compounding Pharmacy in Torrance

23560 S. Madison St., #112, Torrance, CA 90505 (310) 530-0831 / Fax: (310) 530-8218

Is Your Memory Loss Caused by Insomnia?

If you are noticing you are a bit more forgetful than usual, you may be suffering memory loss caused by insomnia. Fill out this questionnaire and one of our team members will contact and discuss your answers with you.
Do you regularly sleep fewer than seven hours each night?*
- Yes
- No
- Unsure
Does it usually take more than half an hour for you to fall asleep?*
- Yes
- No
- Unsure
Do you have trouble getting to sleep three nights or more each week?*
- Yes
- No
- Unsure
Have your sleep issues lasted for a month or longer?*
- Yes
- No
- Unsure
Do you wake up several times during the night?*
- Yes
- No
- Unsure
Do you regularly wake up earlier in the morning than you'd prefer?*
- Yes
- No
- Unsure
When you wake up, do you still feel tired?*
- Yes
- No
- Unsure
Do you have trouble staying awake during the day?*
- Yes
- No
- Unsure
Has your fatigue begun to interfere with your work, family, or social life?*
- Yes
- No
- Unsure
Are you under a lot of stress?*
- Yes
- No
- Unsure
Anything else you want us to know about?
Your Name*
Email*
The information you provide will only be used for the purposes of this survey. Survey taken from "What You Must Know About Memory Loss & How You can Stop It" by Pamela Wartian Smith, MD, MPH (p 84).