Order details for LYNNE NEWBERRY

Selected Prescriptions

Ambien (Zolpidem) Extended-Release 10mg

3 Months Pack (90 Count)

Patient Profile

  • Gender: Female (70 Yrs)
  • DOB: Jul 02, 1955
  • Height: 5'5.50"
  • Weight: 128 lbs

Shipping To

Ms. NEWBERRY
140 S CITRUS ST
ORANGE, CALIFORNIA
92868

Contact Info

(714) 920-9573

IP: 103.211.14.114 Order Date: Feb 09, 2026, 10:05 AM

SLEEP INTAKE RECORD:

Submitted: Feb 9, 2026

Patient Name

Ms. LYNNE NEWBERRY

DOB: 07/02/1955 (70 Yrs)

Contact Info

(714) 920-9573

Physical Profile

Weight: 128 lbs Height: 5'5.50"

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 ✓