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*
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)

Difficulty falling asleepDifficulty staying asleepWaking up too earlyDifficulty waking up when you want
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?

YesNo
Does anyone in your family have sleep problems?

YesNo
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?

YesNo
Please provide the list of your allergies below*
Do you use any medications?*

YesNo
Please list the names, strengths, and dosages of your medications, along with how you take them, in the space below.*

Medical History

	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?

Female Patients Only
Date of your last period

MonthDayYear
Date
Current contraceptive/Birth control use:

Oral contraceptionIUD (Mirena, copper IUD)Tubal ligation (tubes tied)Hysterectomy and/or ovaries removedNone
Is there a specific medication you would like to request?*

YesNo
What is your requested medication name and dose?*
Do you agree to receive text reminders for your appointment?*

YesNo
Should be Empty:

Appointment Form

SLEEP PROBLEM

SLEEP HABITS

Medical History

Female Patients Only