Sleep History

Bedtime/waketime, sleep latency, awakenings, duration, naps, sleep hygiene, screen/caffeine/alcohol timing, and shift work.

Snoring, witnessed apneas, gasping, restless legs, parasomnias, nightmares, daytime sleepiness, and red flags.

Sleep Measures

Bedtime:

Wake time:

Sleep latency:

Awakenings:

Naps:

Snoring / witnessed apnea:

Restless legs / movement:

Daytime sleepiness (ESS score if used):

Insomnia severity (ISI score if used):

Sleep quality (PSQI score if used):

0/10 Score

0 of 4 Answered

Incomplete High risk is 5 or more.

Criterion	Points
Waist circumference at umbilicus above threshold	0/3
Has snoring ever bothered other people?	0/3
Has anyone noticed the patient stop breathing during sleep?	0/2
Aged 50 years or over	0/2

OSA red flags reviewed: snoring, witnessed apneas or gasping, excessive daytime sleepiness, drowsy driving risk, resistant hypertension, obesity or large neck circumference, craniofacial risk.

Safety counseling completed for drowsy driving or sedating substances when indicated.

Focus	Documentation
Sleep impression	Summarize insomnia, circadian, OSA, RLS, parasomnia, medication/substance, and psychosocial contributors. Sleep impression: Red flags / differential: Functional impact:
Recommendations	Record sleep hygiene, schedule, CBT-I skills, labs/referral, and safety-sensitive advice. Recommendations: Referral / testing: Patient instructions:
Monitoring	Set sleep diary or measure, target symptoms, follow-up interval, and escalation criteria. Measure / diary: Target symptoms: Follow-up:

Focus

Documentation

Sleep impression

Summarize insomnia, circadian, OSA, RLS, parasomnia, medication/substance, and psychosocial contributors.

Sleep impression:

Red flags / differential:

Functional impact:

Recommendations

Record sleep hygiene, schedule, CBT-I skills, labs/referral, and safety-sensitive advice.

Recommendations:

Referral / testing:

Patient instructions:

Monitoring

Set sleep diary or measure, target symptoms, follow-up interval, and escalation criteria.

Measure / diary:

Target symptoms:

Follow-up: