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Insomnia

HISTORY:
Insomnia for  
Type: 
Awakenenings:  times during the night, taking   to fall back asleep
Total sleep time:  hours per night
Impact on daily activities: 
Treatments tried: , 







Other elements:

EXAM:
General appearance: 
Vital signs: , BP , HR , RR , SpO2  %, Temp °
Neck: 
Heart: , 
Lungs: , 
Abdomen: , , , 
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait 
Mental status: , , speech , mood , thought process , , judgment 

ASSESSMENT:
 
DDx: 

PLAN:
- Sleep diary
- Sleep study
- Good sleep hygiene: maintain a consistent sleep schedule of 7-8 hours, dim lights and avoid screens before bedtime, ensure a dark and cool sleep environment, and refrain from taking a naps
- Avoidance of caffeine, drugs, stimulants, and alcohol
- Cognitive behavioral therapy
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- Referral to psychologist
- Referral to sleep specialist
- Follow-up in  
- Return if insomnia worsens or if new symptoms develop such as mood disturbances