Patient Form Submission7. Medical HistoryPlease complete all applicable fields. An asterisk (*) indicates a required field. Name * First Name Last Name Date of birth * MM DD YYYY Past Medical History Check off all that apply. obstructive sleep apnea chronic insomnia restless leg syndrome narcolepsy type 1 ("with cataplexy") narcolepsy type 2 ("without cataplexy") hypertension/high blood pressure hyperlipidemia/high cholesterol diabetes heart attack coronary artery disease acid reflux/heart burn nasal allergies hypothyroidism hyperthyroidism fibromyalgia major depressive disorder generalized anxiety disorder asthma Other past medical history Please fill in any additional conditions you have below. Past surgical history Please list any surgeries you have had below. Family history Please list any relevant family medical history below. Marital status married single divorced other Employment Please list your current employer or type unemployed. Thank you!