Patient Information
Full Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Phone Number
Email Address
Address
Medical History
Primary Care Physician
Current Medications
Allergies
Relevant Medical or Psychiatric Conditions
Sleep Concerns
Main Reason for Visit
How long have you been experiencing sleep problems?
Describe your sleep issue
Typical Bedtime
Typical Wake Time
How long does it take you to fall asleep?
How many times do you wake up during the night?
Do you snore or has anyone observed breathing pauses during your sleep?
Yes
No
Not sure
Lifestyle & Habits
Caffeine Consumption (type, amount, and timing)
Alcohol Use
Tobacco or Recreational Drug Use
Physical Activity (type and frequency)
Other Notes
Additional Information or Concerns