Form - Quetiapine – DIMA Health Technology Inc.

You are one step closer to get your Quetiapine!

Please fill this questionnaire to complete your order.

Please enter your first name:

Please enter your last name:

Please enter your email:

What was your sex assigned at birth?

Male

Female

How old are you?

Is your problem mainly falling asleep, staying asleep, or both?

Falling Asleep

Staying Asleep

How long have you had a problem falling asleep or staying asleep?

Less than 3 months

3-12 months

More than a year

How many times a week do you have a problem falling asleep or staying asleep?

Once a week

About 2-3x per week

Nearly every Day

Do you go to the bed at the same time every day?

Yes

No

Are you sleepy at bed time?

Yes

No

Do you get up at the same time every day?

Yes

No

How anxious are you about having problems falling asleep or staying asleep?

Not at all

Somewhat anxious

Very anxious

How often do you nap or doze during the day?

Once a week

2-3x/week

Nearly every day

Rarely or never nap

Has difficulty with sleep caused problems with work or home life?

Yes

No

What have you noticed? Select all that apply to you.

Which treatments have you tried for insomnia? Select all that apply to you.

Prescription medicines

Over-the-counter sleeping medicines (Tylenol PM, Advil PM, ZZZQuil, etc.)

Counseling or coaching

Meditation or mindfulness

Herbal or dietary supplements (Valerian, Chamomile, Kava, Melatonin)

Other

None of the above. I have never been treated for insomnia

Have you ever had any of the following behaviors when NOT fully awake when taking prescription sleeping medicine? Select all that apply to you.

Sleep walking or excessive movement while asleep or not fully awake

Sleep driving

Making telephone calls while not fully awake

Cooking while not fully awake

Eating while not fully awake

Having sex while not fully awake

No, I have never had any of these behaviors

Over the past two weeks, how often have you been bothered by: little interest or pleasure in doing things?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by: feeling down, depressed, or hopeless?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Feeling nervous, anxious, or on edge?

Not at all

Several days

More than half of the days

Nearly every day

Over the past two weeks, how often have you been bothered by - Not being able to stop or control worrying?

Not at all

Several days

More than half of the days

Nearly every day

Have you ever been diagnosed with bipolar disorder or manic depression?

Yes

No

No, but there is family history of bipolar or manic depression

Have you ever had over 1 week of just racing thoughts, decreased need for sleep, reckless behavior or euphoric or irritated mood not due to drugs?

Yes

No

Have you ever been diagnosed with any of the following medical conditions? Select all that apply to you.

Psychosis

Schizophrenia

Eating disorder, bulimia, or anorexia

Suicide attempt

Self-harming behavior - like cutting

Serotonin syndrome

None apply

Some medical conditions can cause problems with sleep. Which of the following diagnoses have you had or currently have? Select all that apply to you.

Have you been diagnosed with any of the following medical conditions which can impact the medicines we prescribe? Select all that apply to you.

Do you have other medical conditions?

Are you currently working?

Yes

No

Have there been any changes in your work, home life, or general health?

Yes

No

Do you smoke or use other tobacco products?

Yes

No, I quit

Never smoked

Do you currently drink alcohol or alcoholic beverages?

Yes

No. I don't drink

(If yes) How much do you drink?

Drink up to 1 drink per day

Drink 1 to 2 drinks a day

More than 2 drinks per day

More than five drinks at one time for five days in a row at some point over the past 30 days

I don’t drink

Do you or did you use drugs? This includes using needles, marijuana, ecstasy (MDMA), stimulants, uppers, etc.

Yes

Never

Are you allergic to any medicines? If yes, please list them below.

Are you currently taking any prescription medicines?

Are you taking nasal sprays (for example Patanase or Astepro), inhalers (for example Atrovent or Spiriva), vitamins, herbs, over-the-counter products such as pain relievers, dietary supplements (for example Potassium Citrate) and any sleep aids (for example Benedryl, Zquil, Tylenol PM or Unisom)?

Yes

No

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