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Demographics and Medical History Questionnaire

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First Name: *

Last Name: *

Date:

05/12/2020

Date of Birth:

Year

Month

Day

Age:

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?

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:

Year

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?

Yes    
No

If yes, when?

Why?

Are you currently involved in litigation?

Yes    
No
 
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