Sleep Survey – Neurovalens

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Your sleep

7 Questions

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Your health

8 Questions

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Your details

7 Questions
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What are you looking for help with?*

Falling asleepStaying asleepWaking up too earlyPoor sleep quality (Feeling unrested even after sleep)

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Your sleep

7 Questions

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Your health

8 Questions

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Your details

7 Questions
You’re not alone!

Research indicates that approximately 30% of adults experience chronic insomnia at some point in their lifetime.

Journal of Clinical Sleep Medicine, 2007

Here’s the good news!

95% of Modius Sleep clinical trial participants noticed an improvement in their sleep in just 4 weeks.

Neuroscience 2024, Society of Neuroscience

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Your sleep

7 Questions

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Your health

8 Questions

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Your details

7 Questions
How do your sleep problems affect your day-to-day life?*

Low energy / fatigueLack of concentration or focusLow moodIrritability or mood swingsReduced productivity in work or educationDifficulty maintaining relationships or social connectionsIncreased stress or anxiety

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Your sleep

7 Questions

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Your health

8 Questions

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Your details

7 Questions
Sleep impacts every aspect of your life, and you’re not alone in experiencing these challenges:

The good news? Modius Sleep is designed to help you break free from these challenges and regain control of your day-to-day life.

“
I've been using Modius Sleep for a few months and I've noticed I stay asleep longer, fall asleep easier, and haven’t had those 'sleep never comes' nights. Before, I’d lie in bed for hours and just couldn’t fall asleep. That hasn't happened since I started using Modius Sleep.

Jaikiah

Master Hair Stylist | NYC

“
I’ve had insomnia since 2020. A colleague recommended Modius Sleep. I was unsure at first—I’d tried so many things. But the results were instant. After a week, I was sleeping a solid 7 hours. I could function better at work and be a better parent. It’s given me my life back.

Perry

Employee, Dad, Traveller

“
I’ve tried Ambien, Doxepin, sleep patches, and therapy. I've tried everything. Nothing worked! Until I received my Modius Sleep and within a few nights, I was sleeping 4–5 hours, then 6–8, then 8–9. Last night, I slept 10 straight hours. Amazing for me.

Jan

Chronic Insomnia for 50 years
*Individual results may vary

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Your sleep

7 Questions

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Your health

8 Questions

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Your details

7 Questions
What are you currently doing to address these issues?*

CBT-I TherapySleeping pillsDiet changesRelaxation techniques (meditation, yoga)Sleep tracking appsOver-the-counter sleep aids (Melatonin)Lifestyle changes (reducing screen time, improving sleep hygiene)Nothing yet

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Your sleep

7 Questions

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Your health

8 Questions

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Your details

7 Questions
Addressing sleep challenges can feel overwhelming, but Modius Sleep is designed to fit effortlessly into your daily routine. Simply wear this non-invasive, drug-free headset for 30 minutes each evening before bed.

Unlike other approaches that may only mask the symptoms, Modius Sleep is an FDA cleared solution that treats chronic insomnia.

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Your sleep

7 Questions

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Your health

8 Questions

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Your details

7 Questions
How long have you been experiencing problems with your sleep?*

Less than 1 month1-3 monthsMore than 3 months

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Your sleep

7 Questions

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Your health

8 Questions

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Your details

7 Questions
How many nights per week do you experience sleep disturbances of any kind?*

1-2 nights3-4 nights5-6 nightsEvery night

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Your sleep

7 Questions

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Your health

8 Questions

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Your details

7 Questions
Do you go to bed at a reasonable time, in a comfortable and safe space, and still experience poor sleep?*

Yes - my sleep schedule and environment are ideal and I still experience poor sleepNo - my sleep schedule and/or environment could be improved

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Your sleep

7 Questions

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Your health

8 Questions

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Your details

7 Questions
Are you familiar with Modius Sleep?*

No, I've never heard of itI know a little about itYes, I know all about it
No problem! Here’s what you should know:

Modius Sleep is a new FDA cleared medical device that is prescribed to treat chronic insomnia.

Modius Sleep works by applying a small and safe electrical pulse to activate the parts of your brain responsible for regulating your sleep. The technology is entirely non-invasive and the headset is worn for 30 minutes per day before you go to bed.

Independent clinical studies show that Modius Sleep successfully treats chronic insomnia over a period of four weeks; showing improvement in insomnia symptoms, overall sleep quality and increased energy levels
Great! Here’s a little more info:

Modius Sleep is a new FDA cleared medical device that is prescribed to treat chronic insomnia.

Modius Sleep works by applying a small and safe electrical pulse to activate the parts of your brain responsible for regulating your sleep. The technology is entirely non-invasive and the headset is worn for 30 minutes per day before you go to bed.

Independent clinical studies show that Modius Sleep successfully treats chronic insomnia over a period of four weeks; showing improvement in insomnia symptoms, overall sleep quality and increased energy levels.
Fantastic! Great to have an expert on board. We’ll skip the science lesson and move straight to the next sesction so we can get you started on your journey to better sleep.

Great

Now let's look at your medical history to understand more about your sleep.

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Your sleep

7 Questions

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Your health

8 Questions

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Your details

7 Questions
Why we ask these questions

These questions help us and your physician better understand your unique sleep challenges and any contributing factors and helps us ensure that Modius Sleep is the right fit for you..
Have you ever been diagnosed with chronic insomnia?*

YesNo

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Your sleep

7 Questions

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Your health

8 Questions

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Your details

7 Questions
Could your sleep problems be better explained by another condition?*

Another sleep disorder (e.g., sleep apnea, restless leg syndrome)A medical condition (e.g., chronic pain, hormonal imbalances)Substance use (e.g., caffeine, alcohol, medications)Mental health issues (e.g., anxiety, depression, PTSD)None of the aboveOther

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Your sleep

7 Questions

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Your health

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Your details

7 Questions
Are you currently taking any medications that may impact your sleep?*

YesNo
Please list your medications:*
Do you have any other medical conditions we should be aware of?*

YesNo
Please describe your medical conditions:*
Do you have any allergies?*

YesNo
Please list any allergies:
Do you have any questions for the doctor?

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Your sleep

7 Questions

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Your health

8 Questions

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Your details

7 Questions
Modius Sleep is a safe and effective device, but it cannot be used with the following conditions. If any of these apply to you, please let us know. If none apply, you can leave this question blank.
Are any of the following true for you?

I am under the age of 22I am pregnantI have an implanted pacemaker, cardiac defibrillator, or neurostimulation deviceI have vestibular dysfunction or inner ear diseaseI suffer from RVE (Reflex Vestibular Epilepsy)I am suffering from a skin condition affecting the skin behind the ears (e.g., eczema, rashes or broken skin)
Vestibular dysfunction and inner ear disease - severe problems with the inner ear that affect balance, coordination, or cause symptoms like severe dizziness or frequent loss of balance.

RVE (Reflex Vestibular Epilepsy): a very rare form of epilepsy triggered by specific movements or stimulation of the balance system (unrelated to generalised epilepsy).

Skin irritation behind the ears: It’s best not to use Modius Sleep until the skin has fully healed. Using Modius Sleep on irritated skin could worsen the condition or cause discomfort.

Modius Sleep may not be the right fit for you at this time.

You've told us:

{areAny}

Based on this information, it seems that Modius Sleep may not be suitable for you.

Your health and safety are our top priorities. We encourage you to speak with your physician to explore other options that may better suit your needs.

Just a few more questions

This helps us verify your identity and ensure your Modius Sleep device is delivered to the right place.

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Sleep history

5 Questions

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Medical history

7 Questions

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Your details

7 Questions
Name*

First NameLast Name
Email*
[email protected]
Date of Birth*

MonthDayYear
Sex Assigned at Birth
Enter US Phone Number*
Shipping Address*

Street Address

Street Address Line 2

CityState

Zip Code
Please upload a photo of your US Government Issue ID*
I confirm that the information I have provided is accurate and true, and I give consent for my submission details to be shared with Beluga Health for the purpose of a prescription assessment.*

I confirm
Should be Empty:

You’re not alone!

Great

Why we ask these questions

Modius Sleep may not be the right fit for you at this time.

Just a few more questions