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You are one step closer to get your Quetiapine!
Please fill this questionnaire to complete your order.
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Please enter your first name:
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What was your sex assigned at birth?
Male
Female
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How old are you?
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Is your problem mainly falling asleep, staying asleep, or both?
Falling Asleep
Staying Asleep
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How long have you had a problem falling asleep or staying asleep?
Less than 3 months
3-12 months
More than a year
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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
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Do you go to the bed at the same time every day?
Yes
No
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Are you sleepy at bed time?
Yes
No
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Do you get up at the same time every day?
Yes
No
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How anxious are you about having problems falling asleep or staying asleep?
Not at all
Somewhat anxious
Very anxious
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How often do you nap or doze during the day?
Once a week
2-3x/week
Nearly every day
Rarely or never nap
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Has difficulty with sleep caused problems with work or home life?
Yes
No
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What have you noticed? Select all that apply to you.
Fatigue or malaise
Poor attention or concentration
Problems socially, at school or work
Mood disturbance or irritability
Daytime sleepiness
Decreased motivation or energy
Increased errors or accidents
More on edge, impulsive or aggressive
Constant worry about sleep
Other
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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
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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
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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
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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
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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
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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
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Have you ever been diagnosed with bipolar disorder or manic depression?
Yes
No
No, but there is family history of bipolar or manic depression
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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
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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
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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.
Mental health issues including ADHD, PTSD, anxiety, depression, mood disorders, etc.
Breathing issues or difficulty including asthma, emphysema (COPD), or sleep apnea
Problem with urination
Arthritis
Heartburn / GERD
Menopause
Parkinson's Syndrome
Restless legs syndrome (RLS)
Pregnancy
Breastfeeding
None apply
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Have you been diagnosed with any of the following medical conditions which can impact the medicines we prescribe? Select all that apply to you.
Kidney problems including having had a kidney transplant
Liver problems
Seizure disorder or epilepsy
History or family history of QT prolongation / EKG abnormalities
Glaucoma or family history of narrow or angle-closure glaucoma
Diabetes
High blood pressure
High cholesterol
Heart disease or heart attack
HIV
Cancer, or history of cancer
Thyroid or other hormone condition
Migraine headaches
None
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Do you have other medical conditions?
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Are you currently working?
Yes
No
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Have there been any changes in your work, home life, or general health?
Yes
No
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Do you smoke or use other tobacco products?
Yes
No, I quit
Never smoked
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Do you currently drink alcohol or alcoholic beverages?
Yes
No. I don't drink
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(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
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Do you or did you use drugs? This includes using needles, marijuana, ecstasy (MDMA), stimulants, uppers, etc.
Yes
Never
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Are you allergic to any medicines? If yes, please list them below.
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Are you currently taking any prescription medicines?
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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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