We ask these questions to ensure that any medication prescribed is safe based on your biological sex and pregnancy status.
What was your sex assigned at birth?
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Are you currently pregnant, breastfeeding or planning to become pregnant?
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I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus.
I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.
I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.
By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.
I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.
By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
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Title
Title
Is insomnia new for you?
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Title
Title
Which best describes your needs (select one)
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Title
Title
How many nights per month do you need assistance with sleep medications?
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Title
Title
How long have you been experiencing insomnia?
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Title
Title
How many hours do you sleep on average per night?
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Title
Title
How would you classify the severity of your insomnia?
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Title
Title
What treatments have you tried for insomnia?
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Title
Title
Is this well controlled with a sleep device such as an oral appliance or CPAP/BiPAP
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Title
Title
Do you operate heavy machinery, drive for extended periods, or perform tasks that require high levels of focus and coordination as part of your job?
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Title
Title
How often do you consume caffeine in the afternoon? (coffee, tea, soda)
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Title
Title
How frequently do you consume alcohol?
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Title
Title
Is your sleep environment conducive to rest? (e.g., comfortable bedding, dark room, minimal noise)
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Title
Title
Do you use electronic devices (phone, computer, TV) shortly before bedtime?
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Title
Title
Are you experiencing symptoms of anxiety, depression, or stress which is causing your sleep difficulty?
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Please read this important safety information about this treatment. You have been prescribed a sleep medication to help manage your insomnia. This consent form is designed to provide information about the benefits, risks, and responsibilities associated with its use. Please read the following carefully and ask any questions before signing.
Purpose of Medication
The prescribed sleep medication is intended to assist with difficulty falling asleep, staying asleep, or improving overall sleep quality. It is not a cure for insomnia but may provide temporary relief as part of a broader treatment plan.
Potential Benefits
Potential Risks and Side Effects
While this medication may improve sleep, it also carries certain risks and potential side effects, including but not limited to:
Precautions
Alternative Treatment Options
Non-medication treatments for insomnia may include:
Consent and Acknowledgment
I acknowledge that I have read and understand the information provided above. I understand the benefits, risks, and responsibilities associated with the use of this sleep medication. I agree to take the medication as prescribed and follow up with my healthcare provider as necessary.
Purpose of Medication
The prescribed sleep medication is intended to assist with difficulty falling asleep, staying asleep, or improving overall sleep quality. It is not a cure for insomnia but may provide temporary relief as part of a broader treatment plan.
Potential Benefits
- Improved ability to fall asleep and/or stay asleep
- Increased total sleep duration
- Enhanced daytime functioning and alertness
Potential Risks and Side Effects
While this medication may improve sleep, it also carries certain risks and potential side effects, including but not limited to:
- Drowsiness, dizziness, or difficulty concentrating
- Increased risk of falls or injuries, especially in older adults
- Next-day grogginess or impairment, including while driving or operating machinery
- Dependency, tolerance, or withdrawal symptoms with long-term use
- Unusual behaviors such as sleepwalking, sleep-driving, or engaging in activities while not fully awake
- Interactions with other medications, alcohol, or underlying medical conditions
Precautions
- Avoid alcohol and other sedatives while using this medication.
- Do not drive or operate heavy machinery until you know how this medication affects you.
- Take the medication as prescribed and do not exceed the recommended dose.
- Inform your healthcare provider of any other medications or supplements you are taking.
- Notify your healthcare provider immediately if you experience any unusual side effects, worsening symptoms, or signs of dependency.
Alternative Treatment Options
Non-medication treatments for insomnia may include:
- Cognitive behavioral therapy for insomnia (CBT-I)
- Sleep hygiene practices (e.g., consistent bedtime, reducing screen time)
- Lifestyle modifications, including stress management and regular exercise
Consent and Acknowledgment
I acknowledge that I have read and understand the information provided above. I understand the benefits, risks, and responsibilities associated with the use of this sleep medication. I agree to take the medication as prescribed and follow up with my healthcare provider as necessary.
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Please attest to the following confirming that all information you have provided to us is true and complete.
Consent: I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.
Consent: I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.
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Based on the information you provided, this visit type requires in-person medical evaluation for safe and appropriate care.
What you were seeking help for:
• Insomnia
Why this happens
Some symptoms, medical history details, or risk factors mean a condition can’t be safely managed through telemedicine. A licensed provider must examine you in person to ensure the right diagnosis and treatment.
Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.
