Order details for edward mallett

Selected Prescriptions

Ambien (Zolpidem) Immediate-Release 10mg

2 Months Supply (60 Count)

Patient Profile

  • Gender: Male (80 Yrs)
  • DOB: Dec 01, 1945
  • Height: 5'7.00"
  • Weight: 180 lbs

Shipping To

Mr. mallett
5300 Memorial Drive
HOUSTON, Texas
77007

Contact Info

edward@msblawyers.com

(713) 444-8146

IP: 99.149.180.170 Order Date: Jan 28, 2026, 7:20 AM

SLEEP INTAKE RECORD:

Submitted: Jan 28, 2026

Patient Name

Mr. edward mallett

DOB: 12/01/1945 (80 Yrs)

Contact Info

(713) 444-8146

edward@msblawyers.com

Physical Profile

Weight: 180 lbs Height: 5'7.00"

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 ✓