William S. Middleton VA Sleep H & P Template

William S. Middleton VA Sleep H & P Template

CHIEF CONCERN:

Onset of chief concern

Course since that time:

Sleep pattern before the onset of the sleep problem:

HPI:

Symptom/duration/treatment trials:

The Veteran has difficulty with:

SLEEP-WAKE PATTERNS

Number of times a week trouble falling/staying asleep:

Usual sleep times on a weekday:

Usual sleep times on the weekend:

Work or sleep rotating shifts?

Ever go a whole night or a few nights with no sleep?

Hours of sleep overall per night?

How concerned are you about your sleep problem?

PRE-SLEEP ACTIVITIES

Pre-bedtime routine:

Time to fall asleep:

EVENTS DURING SLEEP

Times and duration awake through the night:

What wakes at night?

What happens when can't fall asleep or return to sleep?

What factors exacerbate sleep problem?

What factors improve sleep problem?

Heartburn/Reflux?

Pain issues?

Nocturia?

Other:

EVENTS UPON AWAKENING

Refreshed?

Morning headaches?

Morning alertness?

DAY ACTIVITIES

Take naps/frequency/duration:

Are these refreshing?

Daytime energy:

Daytime physical/social activities:

Light exposure:

Response to meals:

DAY SYMPTOMS

Abnormal movements?

Difficulty with concentration or memory?

Pain?

Day sleepiness?

Intensity/timing/duration:

Adverse outcomes due to day sleepiness?

Anxiety:

Low Mood:

APNEA

Snoring?

Breathing pauses?

Shortness of breath?

Choking?

Dry mouth?

RLS/PLMS

Crawling/aching/unpleasant sensations in legs?

More at evening/night?

More when still?

Improved with movement?

When did such start?

How many nights a week and what hours?

Medication changes around that time?

Kicking or twitching at night?

PARASOMNIAS

Sleepwalking or sleep talking?

Acting out dreams?

Odd behaviors at night?

Nightmares or night terrors?

Bruxism?

NARCOLEPSY

Fall asleep at inappropriate/unintentional times and places?

Episodes off sudden loss of muscle tone?

Sudden sleep attacks?

Sleep paralysis?

Hypnogogic hallucinations?

SUBSTANCES/HABITS

Alcohol:

Nicotine:

Caffeine:

Other drugs:

Exercise:

Diet:

INSOMNIA

Ruminating/racing thoughts

Watches TV/read in bed

Work in bed

Checking clock

Eating late

Smoking late

Exercise late
ETOH for sleep
When cannot sleep…does what

Partner’s sleep

Apprehension or worry about sleep?

Fear of sleeping?

Fear of waking up?

MEDICATIONS

|ACTIVE OUTPATIENT MEDICATIONS|

Over the counter meds:

Herbs:

Other substances:

PAST MEDICAL HISTORY

(Oral/Nasal surgeries):

PAST PSYCHIATRIC HISTORY

(Diagnoses/treatments):

FAMILY HISTORY [sleep apnea, insomnia, sleepwalking/night terrors, PLMS, RLS, Narcolepsy, other]

SOCIAL HISTORY

Living:

Sleep environment:

Financial/work:

Social support:

Military history:

ROS:

Weight change:

Nasal congestion:

Resp:

Card:

GI:

GU:

Neuro:

Musculoskeletal:

Mood:

PHYSICAL AND MENTAL STAUS EXAM

ESS: ___/24

Cleveland

PSQI

Examination [PATIENT HEIGHT, WEIGHT, BLOOD PRESSURE, RESPIRATION, PAIN|

GEN:

HEENT: [nasal mucosa uvula; soft palate (low lying); hard palate (narrow, high arched); tongue (macroglossia); mandible (retrognathia/micrognathia);septum (deviated), turbinates (hypertrophy)]

Neck [circumference]:

Chest:

COR:

Ext:

Neuro:

Mood:

Affect:

Cognition:

Additional comments [cogwheeling in joints; edema extremities]

LABORATORY RESULTS

|TSH-II|

|FERRITIN|

|CHEM 7 5Y|

|CREATININE|

|CBC|

Summary of previous PSG, overnight, day studies from VA or outside facility:

ASSESSMENT/FORMULATION:

RECOMMENDATIONS/PLAN:

1.

2. Driving:

3. Follow-up:

Attending sleep physician, Dr. XXX was present and participated in this evaluation, formulation, and treatment planning.