Sleep Clinic Patient Intake Form
Patient Information
First Name
Last Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Phone
Email
Address
Referring Physician
Name
Phone
Medical History
Current Medications
Medical Conditions
Sleep History
Describe your sleep problems
How long have you had these problems?
Current treatments (if any)
Other sleep-related symptoms
Lifestyle and Habits
Do you consume caffeine? (type & amount per day)
Do you consume alcohol? (type & amount per week)
Do you use tobacco? (type & amount per day)
Do you exercise regularly? (type & frequency)
Additional Comments