Please take your time in providing the following information. The questions are designed to help me begin to understand you so
that our time together can be as productive as possible. All information provided is confidential.
If yes, please provide:
Briefly, what brings you in today
What areas of your life have been affected because of this problem?
List Family Member
Are you currently in a romantic relationship?
Please list any medications, herbs, or supplements. Be sure to include the condition, as some medications are prescribed for offlabel use. Continue on the back if needed, or provide a separate list. If you have a complicated medical profile, please supply
supporting documentation to be able to facilitate a comprehensive understanding of your health.
Prescribing provider and contact information:
Please list any specific health problems you are currently experiencing:
Please list any other specific sleep problems you are currently experiencing: