Sleep Consultation Form

Sleep Consultation Form
Personal Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your age
Your gender
Your job title
Do you do shift work or work during the night?
Do you have an exercise routine?
How often do you exercise

Other
Do you smoke?
Indicate your daily usage of tobacco products
Alcoholic beverages consumption
Indicate the daily consumption of caffeinated beverages (in cups)
Sleep Routine
What time do you go to bed?

Hour Minutes

AM/PM Option
What time do you get out of bed?

Hour Minutes

AM/PM Option
Once in bed how long does it take to fall asleep (in minutes)?
How long does it typically take until you are fully awake (in minutes)?
Average hours of sleep per night
Once asleep, how many times do you wake up?
Are your bed and bedroom comfortable, dark, and silent?
Describe your sleeping environment
Do you fall asleep somewhere except in your own bed?
How often do you take naps?
Who do you live or sleep with?
Sleep Issues and Behaviours
When trying to fall asleep, check all that you experience

Other
When waking up, check all that you experience

Other
During the day when you want to be alert and awake, check all that you experience

Other
Medical History
List your current or past health problems
Specify any past surgeries or hospitalizations
Your medications information
Did you experience any allergies, side effects, or other adverse reactions to the medication?
Provide detailed information about any allergies, adverse reactions or side effects
Any thing else you want to add
Your Signature
I confirm that the above information is correct to the best of my knowledge. I will take the responsibility to inform the consultant of any changes to my health or any of the above information.
Signature
Should be Empty:

Sleep Consultation Form

Personal Information

Sleep Routine

Sleep Issues and Behaviours

Medical History

Your Signature