Required fields are marked with an asterisk *. Please fill out the following form and click on "Submit."First Name *Last Name *Date of Birth *Sleep PatternsWhat is your normal bedtime? *Do you have difficulty getting to sleep? * Yes NoIf yes, how long does it take you to get to sleep?How many hours do you sleep before waking up the first time? *Why do you wake up? (Mark all that apply) Light sleeper Pain Hot Cold Snoring Pets OtherIf other, please explain.How many times do you wake up during the night?How long does it take you to get back to sleep?How many total hours do you sleep?Do you rest during the day? * Yes NoPlease rate your quality of sleep on the following scale. * Poor 2 3 4 5 6 7 8 9 GreatDo you ever feel rested when you wake up? * Yes NoIf yes, how many times a week do you wake up feeling rested?What helps you sleep better? (Mark all that apply) Cold room Dark room Fan White noise OtherIf other, please explain.Do you use medications to sleep? * Yes NoIf so, what medications work for you?Have you ever tried medications that have not worked? * Yes NoIf so, please list the medications that did not work.Nutritional Habits and Fitness LimitationsWhat time of day is your first meal?How many meals do you eat per day?If less than three, why? Nausea Vomiting Not Hungry Not enough time OtherList an example of BREAKFAST.List an example of LUNCHList an example of DINNERDo you snack? * Yes NoIf yes, what kind of snacks do you eat?Do you eat fast food? * Yes NoIf yes, how many times per week?Do you drink caffeinated beverages? * Yes NoIf yes, how much?What time of day is your last caffeinated beverage?Are you familiar with different food groups? * Yes NoOverall, do you think you are a healthy eater? * Yes NoDo you take vitamins or other supplements routinely? * Yes NoIf yes, please list the vitamins and supplements you have taken.What is your profession?How many hours a week do you work?Is your schedule flexible? Yes NoHow many hours do you spend sitting?How many hours do you spend standing?Have you had an ergonomic evaluation (correct sitting/standing guidelines * Yes NoHow many days per month do you miss work?What prevents you from working?Are you on disability? * Yes NoIf yes, how long have you been on disability?What is the main reason for the length of time you have been on disability?Do you participate in any scheduled exercise (work out/aerobics)? * Yes NoIf yes, please list the exercises you participate in.How many times do you exercise per week?Who does the cooking in your household? Are you able to do household chores? * Yes NoIf yes, what chores can you complete? (mark all that apply) Dust Vacuum Laundry Dishes OtherIf other, please explain.SocialDo you drink alcohol? * Yes NoIf yes, how much alcohol do you consume per week?Do you use medical marijuana? * Yes NoIf yes, how much marijuana do you consume per day?Do you use recreational drugs to treat your pain? * Yes NoIf yes, what drugs do you use and how often?Do you use tobacco products? * Yes NoIf yes, how much tobacco do you consume per day?If yes, how many years have you consumed tobacco?Have you been prescribed pain medication? * Yes NoIf yes, who is the prescribing physician?Do you live alone? * Yes NoIf no, who lives with you? Do you have family who understands your condition? * Yes NoWho is your primary support?What are the 3 top stressors in your life right now?Over the last 2 weeks, how often have you been bothered by any of the following problems?Little interest or pleasure in doing things. Not at all Several days More than half the days Nearly every dayFeeling down, depressed, or hopeless. * Not at all Several days More than half the days Nearly every dayTrouble falling or staying asleep, or sleeping too much. * Not at all Several days More than half the days Nearly every dayFeeling tired or having little energy. * Not at all Several days More than half the days Nearly everydayPoor appetite or overeating. * Not at all Several days More than half the days Nearly every dayFeeling bad about yourself — or that you are a failure or have let yourself or your family down. * Not at all Several days More than half the days Nearly every dayTrouble concentrating on things, such as reading the newspaper or watching television. * Not at all Several days More than half the days Nearly everydayMoving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual. * Not at all Several days More than half the days Nearly every dayThoughts that you would be better off dead or of hurting yourself in some way. * Not at all Several days More than half the days Nearly everydayIf you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? * Not difficult at all Somewhat difficult Very difficult Extremely difficult Rate Your Experience Submit Your form has been securely transmitted to the Colorado Chiari Institute! There was an error with the form submission.