Shift Work Sleep Disorder Intake Form
Full Name
Date of Birth
Phone Number
Email Address
Occupation
Employer
Type of Shift Work
Fixed Night Shift
Rotating Shifts
Early Morning Shift
Other
Describe your current shift schedule (hours, days, rotation)
How long have you experienced sleep difficulties?
What sleep difficulties do you experience?
How does your shift work affect your sleep and daily functioning?
List current medications, supplements, or substances used to aid sleep or wakefulness
Previous treatments or strategies attempted
Relevant medical or psychiatric history