Order details for Todd Kardamis

Selected Prescriptions

Ambien (Zolpidem) Immediate-Release 10mg

3 Months Pack (90 Count)

Patient Profile

  • Gender: Male (56 Yrs)
  • DOB: Sep 06, 1969
  • Height: 5'8.00"
  • Weight: 165 lbs

Shipping To

Mr. Kardamis
125 marina dr
STRATFORD, Connecticut
06614

Contact Info

tkard@optonline.net

(203) 257-3808

IP: 2605:59ca:4266:1210:a095:1a5b:93fa:22f2 Order Date: Jan 30, 2026, 9:42 AM

SLEEP INTAKE RECORD:

Submitted: Jan 30, 2026

Patient Name

Mr. Todd Kardamis

DOB: 09/06/1969 (56 Yrs)

Contact Info

(203) 257-3808

tkard@optonline.net

Physical Profile

Weight: 165 lbs Height: 5'8.00"

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 ✓