Insomnia Intake Form

Appointment Form

Fill the form below and we will get back soon to you for more updates and plan your appointment.
Name

PrefixFirst NameMiddle NameLast Name
Date of Birth

DayMonthYear
Health Card Number
Version Code
Gender
Phone Number
Format: (000) 000-0000.
Email
example@gmail.com
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
SLEEP PROBLEM
On average, how many total hours of sleep do you get per night?
What is most upsetting about your current sleep? (Check all that apply)
When did your sleep problems start & what set them off (ie., new baby, night shift work, illness, deployment, etc.)?
Have you ever been diagnosed with sleep apnea?
Does anyone in your family have sleep problems?
SLEEP HABITS
What time do you get into bed? (ie. 10:00 pm)
What time do you turn your lights off? (ie. 10:30 pm)
How long does it take you to fall asleep after lights out? (ie. 60 minutes)
How many times do you wake up through the night? (ie. 2 times)
How long are you awake in the middle of the night if you total up all the times you wake up? (ie. 30 minutes)
How long are you awake in the middle of the night if you total up all the times you wake up? (ie. 30 minutes)
What time do you wake up in the morning? (ie., 5:00 am)
Medical History
Do you have any food or drug allergies?
Please provide the list of your allergies below
Do you use any medications?
Please list the names, strengths, and dosages of your medications, along with how you take them, in the space below.

Medical History

Rows	Yes	No
History of Glaucoma?
History of Palpitations?
History of Chest pain?
History of Headaches?
History of Kidney Stones?
History of Seizures?
History of Head trauma?
History of radiation to the brain?
History of Pancreatitis?
Personal or family history of thyroid cancer?

Appointment Form