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First Name: *
Last Name: *
Date:
03/12/2024
Date of Birth:
Year
Month
Day
Age:
Marital Status:
Cell #:
E-mail: *
Occupation:
Employer:
Referring Physician:
Family Physician:
Country
Gender:
Health Care Number:
City:
Home Phone #:
Postal Code: *
Work Phone #:
Please describe your sleep problems and why you think they may have occurred: *
How long have you had trouble with your sleep?
Do you have trouble with daytime sleepiness?
For how many weeks/months/years?
Do you have trouble with fatigue?
Are you aware of anything that triggered your difficulty sleeping?
Please list all hospitalizations, surgeries, childbirths, or injuries requiring treatment:
Reason for hospitalization
Please list other present or past medical conditions:
Name of illness
Year of onset
Year of diagnosis
Year resolved
If you have seen a psychologist or psychiatrist, or had problems with anxiety or depression, please describe.
Please list all prescription and non-prescription medications including, herbs, vitamins and other supplements taken in the past month:
Name of medication or supplement
Dosage
Date started
Please list other medications you have taken for your sleep in the past:
Please list allergies or known adverse reactions to medications or other substances:
Please list any sleep problems, anxiety, depression or other health problems in your biological parents, siblings and children:
Mother:
Father:
Siblings:
Children:
Please answer the following:
Birthplace :
No. of Siblings :
Formal education level:
Spouse’s occupation:
No. of children:
Have you been on disability?
If yes, when?
Why?
Are you currently involved in litigation?
