Insomnia Home

What happens in bed?
What is your current sleep difficulty? (Mark one or more boxes that pertain to you with an 'x'. You may type into any box or write by hand.)

Difficulty falling asleep: it usually takes minutes hours.
What if you can’t fall asleep?
Stay in bed. Get up and .
This happens about nights a week, times a month.

Frequent awakenings:
times a night, awake minutes hours each time.
Awakened by:
bladder pain noise light hot flashes busy mind
worries depressed thoughts room too hot or too cold
uncomfortable bed hunger
Other .

What if you can’t fall back asleep?
Stay in bed. Get up and .
This happens about nights a week, times a month.

Wake up too early and can’t get back to sleep.
What if you can’t fall back asleep?
Stay in bed. Get up and .
This happens about nights a week, times a month.

Usually go to bed at , fall asleep at , wake up the last time at
and finally get out of bed in AM at .
Variations .

Total number of hours a night usually spent in bed .
Usual total number of hours sleep . I feel that I need hours sleep.

Does this routine vary on the weekend?
If yes, how? .
Any shift work? History of shift work? .

History:
When did this sleeping difficulty start?
.

What was going on in your life then? .

What happens before sleep?
Activities in bed other than sleep or sex: TV, reading,
Other .
Activities right before bed-time:
dramatic/exciting TV, the News, work, computer,
bath/shower, eating, cigarette, alcohol, beverage.

What happens during the day?
Caffeine intake during 24 hours: # servings of
regular coffee, regular tea, green tea, caffeinated soda.
When? .

Alcohol intake: servings. When? .

Naps(s) during the day. When, where, how long?

Exercise: type(s) ,

Number of times per day. per week. What time(s)? .

Sleeping/relaxation aids
Take prescription sleeping pills. Name and dose:
.
Times a week/month. Times a night. Minutes until fall asleep after taking it.

If you’ve tried to come off of them, how successful? .
When started the pills: .
What was going on in your life when you started?
.

Take other sleeping aids?
Melatonin, valerian, chamomile tea, lavender, kava kava
Other . How effective? .

Do you know any relaxation techniques?
tapes/CD’s, yoga, relaxation, prayer,
meditation, soothing music
Other .
Do they help you sleep? yes, no.

Medical History
Snore or stop breathing (partner reports). Restless legs. Frequent nightmares.
Have had a sleep study. When? Results: .
Frequently feel depressed. By anything in particular? .
Anti-depressant medication? Dose .
Often anxious/stressed. By anything in particular?
.
Anti-anxiety medication? Dose .

Do you have?
Heartburn (GERD), Arthritis, Muscular pain,
Thyroid condition, Hyperactivity (ADD, ADHD)

Do you take?
Beta blockers, Decongestants, Thyroid meds,
Ritalin, stimulants
Other psychiatric medication .