Order details for Rosa Graybeal

Selected Prescriptions

Ambien (Zolpidem) Immediate-Release 10mg

3 Months Pack (90 Count)

Patient Profile

  • Gender: Female (75 Yrs)
  • DOB: Nov 24, 1950
  • Height: 5'3.00"
  • Weight: 175 lbs

Shipping To

Ms. Graybeal
128 Pine avenue
PINEVILLE, West Virginia
24874

Contact Info

rmgraybeal@yahoo.com

(304) 651-2023

IP: 2600:387:f:5d15::c Order Date: Jan 30, 2026, 8:08 AM

SLEEP INTAKE RECORD:

Submitted: Jan 30, 2026

Patient Name

Ms. Rosa Graybeal

DOB: 11/24/1950 (75 Yrs)

Contact Info

(304) 651-2023

rmgraybeal@yahoo.com

Physical Profile

Weight: 175 lbs Height: 5'3.00"

1. Experience with Sleep Difficulty Duration

✕ Less than 2 weeks
✕ 2-4 weeks
✓ 1-3 months
✕ More than 3 months

2. Main Sleep Issues

✕ Trouble falling
✓ Trouble staying
✕ Waking too early
✕ Unrefreshing

3. Time to Fall Asleep

✕ < 30m
✓ 30-60m
✕ > 60m
✕ None

4. Disrupted Nights Per Week

✕ 1-2 nights
✓ 3-4 nights
✕ 5-7 nights

5. Hours of Sleep Per Night

✕ < 4 hours
✕ 4-5 hours
✓ 6-7 hours
✕ > 7 hours

6. Daytime Impact

✓ Fatigue
✕ Poor focus
✕ Mood changes
✓ Performance
✕ None

7. Unintentional Daytime Sleep

✕ Yes
✓ No

8. Lifestyle Factors

✕ Caffeine > 2PM
✕ Alcohol for sleep
✕ Screens in bed
✕ Shift work
✓ None

9. Past Treatments/Supplements

✕ Melatonin/Mag
✕ Antihistamines
✕ Prescriptions
✕ CBT-I
✓ None

10. Treatment Effectiveness

✓ Not effective
✕ Somewhat
✕ Very

11. Medical History

✕ Sleep Apnea/Disorders
✕ Mental Health (Dep/PTSD)
✕ Sleepwalking/Behaviors
✕ Substance Misuse
✓ None

12. Current Medications/Substances

✕ Opioids
✕ Benzodiazepines
✕ Regular Alcohol
✕ Other Sedatives
✓ None

Patient Acknowledgment

Short-term use & No-alcohol policy

AGREED ✓