Dr. Adirim Sleep Questionnaire

Malvern Sleep Clinic

Please complete this questionnaire and submit it to the front desk or administrative team prior to your scheduled appointment.

This form requires secure login before submission

To complete and securely submit this form, please click here to log in.

Patient Information

Last Name *

First Name *

Date of Birth *

Family Physician

Prior Sleep Health

Have you had any prior sleep testing?

Prior sleep health diagnoses (e.g., sleep apnea)?

Do you use a CPAP machine? Yes No

General Health

Height

Weight

Allergies

Health conditions and any prior surgeries

Medication list (including vitamins)

Family history of sleep disorders (e.g. sleep apnea) (if yes, who):

Sleep Times

Bedtime (lights-out time)

How long does it take to fall asleep?

Number of wake ups during the night

Final wake time in the morning

Naps (frequency and duration)

Personal History

Occupation

Who do you live with? (Family/Alone/Roommates)

Do you have a driver's license? Yes No

Tobacco (if yes, amount)

Alcohol (if yes, amount)

Cannabis/recreational drugs (if yes, amount)

Safety Advisory Notice: Sleep disorders can be associated with impaired alertness and daytime sleepiness which can impact safety. To be safe, you should never drive a vehicle or operate heavy machinery if you are sleepy. Sleep disorders (as with other health issues) can impact eligibility for driving, piloting and/or workplace licensing with relevant authorities. It is your responsibility to abide by conditions and health declaration components as part of your licensing or job requirements.

Authentication Required: Log into your session context to save or update this record entry.

Dr. Adirim Sleep Questionnaire

About Us

Medical Guide

Opening Hours

Address