Geriatric Sleep Evaluation Intake
Name
Date of Birth
Age
Sex
Female
Male
Other
Date of Intake
Presenting Complaint
Describe your main sleep concern
When did the problem begin?
How often do you experience these symptoms?
Sleep History
Usual bedtime
Usual wake time
Time to fall asleep (minutes)
Number of awakenings/night
Daytime naps (minutes per day)
Describe your sleep quality
Medical History
Please list your medical conditions
Psychiatric history
Current medications
Social & Lifestyle Factors
Alcohol use (amount & frequency)
Caffeine consumption (amount & timing)
Tobacco/nicotine use
Physical activity (type & frequency)
Living situation
Sleep Environment
Describe your sleep environment (light, noise, temperature, bed partner, etc.)
Other Notes
Additional information