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Can’t fall asleep easily.You wake up Several times at night and can't go back to sleepDon't feel refreshed when you awakenWaking with muscle or joint stiffness and achesWake up very earlyOther
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Your legs muscles cramp frequently.Kicking in your sleep.Your legs go limp when you are angry.You feel paralysed in the morning.Get morning headaches.Wake up gasping for air.Have been told that you snore.None of these apply
0 - 30 minutes31 - 60 minutesMore than 1 hour
0 to 1 night2 nights3 nights4 nights5 to 7 nights
Very goodGoodAveragePoorVery poor
Not at allA littleSomewhatMuchVery much
Less than one month1 to 2 months3 to 6 months7 to 12 monthsLonger than a year
SittingWatching TVLying down to rest in the afternoonDuring social eventsOther
Please list your drug allergies and what happens when you use that drug.
Please include any antibiotics, name of birth control, as well as any over-the-counter and herbal dietary or potassium supplements.
In order for us to provide you with the best care, please let us know what medications you take and what conditions you have.
NonePregnant or planning to become pregnantBreastfeedingHistory of kidney problemsHistory of liver problemsA diagnosed immune disorderOther
Tell us about any concerns or questions you have for the medical team.
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After you submit your request, a licensed medical provider will review your information. You will be notified by email/contact number when that provider has reviewed your request and, if appropriate, made care recommendations.