Sleep Consultation Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Your age

Your gender

FemaleMale

Your job title

Do you do shift work or work during the night?

YesNo

Do you have an exercise routine?

YesNo

How often do you exercise

Do you smoke?

YesNo

Indicate your daily usage of tobacco products

Alcoholic beverages consumption

Indicate the daily consumption of caffeinated beverages (in cups)

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?

YesNo

Describe your sleeping environment

Do you fall asleep somewhere except in your own bed?

UsuallyOftenRarelyNever

How often do you take naps?

DailyA few days in a weekRarelyNever

Who do you live or sleep with?

When trying to fall asleep, check all that you experience

When waking up, check all that you experience

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

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?

YesNo

Provide detailed information about any allergies, adverse reactions or side effects

Any thing else you want to add

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

Sleep Consultation Form

Personal Information

Sleep Routine

Sleep Issues and Behaviours

Medical History

Your Signature