Insomnia Patient Intake Questionnaire
Full Name
Date of Birth
Today's Date
Primary reason for seeking help
Sleep Patterns
How long have you been experiencing insomnia?
How many nights per week do you have difficulty sleeping?
On a typical night, about what time do you:
Go to bed
Try to fall asleep
Fall asleep
Wake up in the morning
Get out of bed
Total sleep time per night (hours)
Number of awakenings per night
How long does it usually take to fall asleep? (minutes)
How long are you typically awake during the night? (minutes)
Do you nap during the day?
Yes
No
If yes, how long and what time of day?
Sleep Environment
Describe your sleep environment (bedroom, noise, light, temperature):
Sleep Medication & Aids
Are you currently taking any medications or supplements for sleep?
Yes
No
If yes, list names, dosage, and frequency:
Lifestyle Factors
Do you consume caffeine?
Yes
No
If yes, what time and how much daily?
Do you consume alcohol?
Yes
No
If yes, what time and how much daily?
Do you smoke or use nicotine?
Yes
No
If yes, what time and how much daily?
Regular physical activity/exercise?
Yes
No
If yes, type, frequency, and time of day:
Mental Health & Medical History
Have you been diagnosed with any medical or psychiatric conditions?
Any recent major life changes or stressors?
Is there anything else you would like to share about your sleep or health?