PATIENT FORM
Title
Mr
Mrs
Miss
Dr
Other
Surname
Given Name
Age
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address with postal code
Email
example@example.com
Mobile Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation
Employer:
Private Health Insurer:
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Emergency Contact:
Name
First Name
Last Name
Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Relation:
Preferred Method of Communication:
Email
SMS
Telephone
Letter
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Medical History
Abnormal Bleeding:
Yes
No
Heart Valve Replacement:
Yes
No
Asthma:
Yes
No
Blood Pressure:
High
Low
Bone Disease:
Yes
No
Cancer:
Yes
No
Cardiac Surgery:
Yes
No
Pregnant:
Yes
No
Smoker/Vape:
Yes
No
Medication (including natural suplements) - (If yes, please list).
Allergies - Please indicate any allergies (e.g., Aspirin, Iodine, Latex, Penicillin, Sulpha drugs, Other). Please specify.
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Detailed Sleep History
Last Sleep Evaluation:
Have you experienced complications or issues during previous sleep therapy?
Yes
No
If yes, please provide details:
Is there any sensitive information you wish to discuss privately and not note down here?
Yes
No
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Sleep-Related Symptoms
Difficulty Falling Asleep:
Yes
No
Difficulty Staying Asleep:
Yes
No
Excessive Daytime Sleepiness:
Yes
No
Snoring
Yes
No
Restless Legs Syndrome (RLS):
Yes
No
Nigthmares:
Yes
No
Insomnia:
Yes
No
Sleepwalking (Somnambulism):
Yes
No
Bruxism (Grinding/Clenching Teeth):
Yes
No
Dry Mouth Upon Waking
Yes
No
Frequent Nighttime Awakenings:
Yes
No
Difficulty Waking in the Morning:
Yes
No
Unexplained Fatigue Despite Adequate Sleep:
Yes
No
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Sleep Apnea History
Have you undergone a sleep study and been diagnosed with sleep apnea?
Yes
No
Have you tried Continuous Positive Airway Pressure (CPAP) therapy?
Yes
No
Has anyone ever noted that you snore loudly or stop breathing during sleep?
Yes
No
Do you feel refreshed after 6-7 hours of sleep?
Yes
No
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Sleep-Related Health Challenges:
Cardiovascular Disease (e.g., hypertension, heart failure):
Yes
No
Metabolic Disorders (e.g., diabetes, obesity):
Yes
No
Psychiatric Conditions (e.g., depression, anxiety):
Yes
No
Neurological Conditions (e.g., epilepsy, Parkinson’s Disease):
Yes
No
Chronic Pain or Fibromyalgia:
Yes
No
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Referral Information:
How did you hear about us?
Google
Website
Referred by Family
Referred by Friends
Dental Care Network
Other…
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Comfort Level:
On a scale of 1-10, how comfortable are you feeling about your appointment today?
Choose bellow:
1
2
3
4
5
6
7
8
9
10
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Sleep Environment Assessment:
How is your bedroom environment?
Is your sleeping environment quiet?
Yes
No
Is your bedroom dark during sleep hours?
Yes
No
Is your mattress and pillow comfortable?
Yes
No
Do you use eletronic devices (e.g., smartphone, tablet, TV), within an hour before bed?
Yes
No
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Lifestyle and Dietary Habits:
Do you consume caffeine after das 4 PM?
Yes
No
Do you consume alcohol within 3 hours of bedtime?
Yes
No
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Exercise
Do you regularly exercise?
Yes
No
Do you exercise within 3 hours of going to bed?
Yes
No
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Psychological Well-being
Do you often feel stressed or anxious?
Yes
No
Do you currently receive treatment for anxiety, depression, or any other psychological condition?
Yes
No
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Sleep Hygiene Practies
Do you have a regular bedtime routine?
Yes
No
Do you have difficulty maintaining a consistent sleep schedule?
Yes
No
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Additional Health Information
Chronic Conditions: Do you suffer from any chronic conditions that may affect sleep (e.g., chronic, pain, gastroesophageal reflux disease)?
Yes
No
Medication Side Effects: Are you currently taking any medications that may affect sleep?
Yes
No
Please list any medications that may affect sleep:
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Privacy Policy & Signature:
I confirm that I have completed this medical form accurately and to the best of my knowledge. I authorize my sleep therapist to use all necessary information and records to provide the best treatment.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Send
Send
Should be Empty: