Have there been any health changes, medication changes, ED visits or hospitalizations since your last check-in?
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Current medication
Current medication
How are you doing on the current medication?
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Current medication
Current medication
On average, how many nights per month do you require medications for sleep?
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Current medication
Current medication
Would you like to continue your current treatment, change the dose, or change the medication?
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Additional Information
Additional Information
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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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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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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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 follow-up
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.
