Order details for GAIL VARGO

Selected Prescriptions

Ambien (Zolpidem) Immediate-Release 10mg

3 Months Pack (90 Count)

Patient Profile

  • Gender: Female (74 Yrs)
  • DOB: Mar 24, 1952
  • Height: 5'1.00"
  • Weight: 130 lbs

Shipping To

Ms. VARGO
45510 163RD ST
WATERTOWN, South Dakota
57201

Contact Info

GVARGO@DAILYPOST.COM

(605) 881-3345

IP: 84.46.141.146 Order Date: Jan 31, 2026, 8:33 AM

SLEEP INTAKE RECORD:

Submitted: Jan 31, 2026

Patient Name

Ms. GAIL VARGO

DOB: 03/24/1952 (74 Yrs)

Contact Info

(605) 881-3345

GVARGO@DAILYPOST.COM

Physical Profile

Weight: 130 lbs Height: 5'1.00"

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 ✓