What is your date of birth?

What is (are) your complaint?

Apply all you have

Do you often change your sleep schedule for work?

Do you have trouble maintaining a consistent sleep schedule?

On most days, how long does it take you to fall asleep?

How many nights a week do you have a problem with your sleep?

How would you rate your sleep quality?

To what extent did poor sleep affect your work?

How long have you had a problem with your sleep?

Do you feel sleepy during the day?

When you doze off during the day?

Do you dream vividly?

Do you often feel sad or depressed?

Do you want to tell us anything else?

Are you allergic to any medicine?

Do you take other medication(s) or have any other medical conditions?

Please include any antibiotics, name of birth control, as well as any over-the-counter and herbal dietary or potassium supplements.

Do you have any of these conditions?

Anything else you would like us to know?

How would you like to pay?

Billing and delivery details

Personal Details

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