Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Sleep Medicine Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Primary Sleep Concern
Sleep Schedule (Weekday/Weekend)
Epworth Sleepiness Scale
STOP-BANG Sleep Apnea Screen
Additional details
Insomnia Symptom Assessment
Snoring & Breathing Symptoms
Restless Legs Screening
Prior Sleep Study Results
CPAP / Oral Appliance History
Current Sleep Medications
| Medication | Dose | How often |
|---|---|---|
Caffeine & Stimulant Use
Consent & Signature
Date
Sleep Medicine Intake Form template from formisoft.com. formisoft.com/intake-templates/sleep-medicine-intake