Sleep Disorder Questionnaire

1

Date of birth

Date

2

Gender

Male

Female

N/A

3

Blood Pressure

4

BMI

5

I smoke cigarettes on a regular basis. Number per day:

6

I drink coffee on a regular basis. Number of cups per day:

7

I drink alcohol before bed/as a nightcap. Number of drinks per night:

8

Health HistorySelect all that Apply

I have frequent urination at night

I eat a lot of spicy food/I get indigestion often

I am overweight

I suffer from depression

I have a history (or family history) of heart disease

I have high blood pressure

I have high cholesterol

I have diabetes

I am on medication

10

Name

First Name

Last Name

11

Email

example@example.com

12

Phone Number

Area Code

Phone Number

13

Health Results

14

Sleep Results