Sleep Readiness

Name of the Patient *

Name of the Doctor *

Contact Number of Patient / Referring Doctor *

Email Address *

Date of Birth *

Please describe how intensely you experience each of the symptoms mentioned below as you attempt to fall asleep by choosing appropriate alternative answer.

1. How much you feel – Heart racing, pounding or beating irregularly. *

2. How much you feel – Shortness of breath or labored breathing. *

3. How much you feel – A tight, tense feeling in your muscles. *

4. How much you feel – Cold feeling in your hands, feet or your body in general. *

5. How much you feel – Have stomach upset (knot or nervous feeling in stomach, heartburn, nausea, gas etc.). *

6. How much you feel – Perspiration in palms of your hands or other parts of your body. *

7. How much you feel – Dry feeling in mouth or throat. *