Sleep Disorder Test

Personal Information

First Name(Required)

First Name

Last Name(Required)

Last Name

Email(Required)

Address(Required)

Street Address Address Line 2 City State Zip Code

Phone(Required)

Phone

Medical Insurance

Current Treating Doctor

Your age(Required)

Sleep Disorders Test

Please answer the following questions. Dr. Khan will use your answers to evaluate your current sleep condition.

How long have you been dealing with sleep issues?(Required)

How long have you been dealing with sleep issues?

What are you having more trouble with?(Required)

What are you having more trouble with?

Falling asleep

Staying asleep

How many times do you usually wake up at night?(Required)

How many times do you usually wake up at night?

Not at all

Once

Twice

3+ times

How long does it usually take you to fall asleep?(Required)

How long does it usually take you to fall asleep?

About 10 minutes

15-20 minutes

1-2 hours

2-4 hours

5+ hours

Do you find it difficult to wake up in the morning or feel weak/tired?(Required)

Do you find it difficult to wake up in the morning or feel weak/tired?

Not at all

Yes, sometimes

Yes, always

Do you feel irritated around people?(Required)

Do you feel irritated around people?

Yes

Do you have any trouble concentrating/focusing?(Required)

Do you have any trouble concentrating/focusing?

Yes

Does your lack of sleep causes you to feel sad/down?(Required)

Does your lack of sleep causes you to feel sad/down?

Yes

Which of the following is more relevant to you?(Required)

Which of the following is more relevant to you?

I would like to get help and find the root cause of my sleep disorder and take any action needed to improve my quality of sleep.

I am not interested or hesitating about investing in getting help and finding the root cause of my sleep disorder.

Medical History Info

Your information is kept confidential with our clinic

Have you been diagnosed by a clinician with any of the following conditions?: Parkinson’s, alzheimer's, dementia, traumatic brain injury, hormone imbalance, overactive thyroid, bipolar disorder or untreated or treatment-resistant depression, psychosis, schizophrenia, seizures, suicidal thoughts.(Required)

Yes

Have you been experiencing any of the following?: Sleep related stress/anxiety | Dread going to bed at night | Racing mind at night | Constantly thinking about your sleep issues | Worrying about the effects of your lack of sleep | Feeling tired and sleepy, except when going to bed(Required)

Yes

Name

This field is for validation purposes and should be left unchanged.

The following assessment form will help Dr. Khan evaluate your current condition and needed treatments.

Please answer all questions carefully.

Personal Information

Sleep Disorders Test

Medical History Info

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