Sleep Questionnaire

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Fill Out The Sleep Questionnaire Below

Please fill out the form below, in its entirety, for us to gain the knowledge we need to help you with any sleep issues. We are happy to help!
  • List prescription and over-the-counter medications including name, dosage, frequency, and purpose.

    If you have multiple medications list like this...
    Medication Name 1 / Dosage / Frequency / Purpose
    Medication Name 2 / Dosage / Frequency / Purpose
  • General Health History | Neurological

  • General Health History | Cardiovascular

  • General Health History | Endocrine Disease

  • General Health History | Allergies

  • Snoring / Apnea / Respiratory / Nasal-Oral Obstruction

  • Insomnia

  • Narcolepsy

  • Parasomnias

  • Gastroesphagealreflux

  • Chronic Pain / Nocturnal Discomfort

  • Nocturia

  • Caffeine / Tobacco / Alcohol Use

    How many caffeinated beverages do you consume per day on average?
  • Sleep Hygiene / Bedtimes

  • Sleep Environment / Sleep Surface / Sleep Position