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History
Physical Exam
Assessment
Test Results
Diagnosis
Plan
Summary
Charactanstics
Can you describe a typical nights sleep?
When I was sleeping normally I would go to bed wound 10-11 pm, immediately tall asleep within minutes and would wake up around 7 am, 1 slapt straight through. Now I try to go to bed and toes and turn for an hour. sometimes two. Then sometimes wake up at 2 or 3 am and have troubis getting back to sleep
Characteristics
Why do you weup
I have no idea junt do
Characteristics
Do you nap during the day?
Never, but I am roudy tre
Characteristics
Is your probiam falling asleep or awakening early?
Both actually. Can you prascibe sleeping pill?
Charactanstics
Do you take anything to help you sleep?
No, but I'm hoping you can give me something for
Aggravating
Roleving
Timing Treatments
What do you do when you cannot fast asleep?
just hy to get up and do some housework and then go back to bed a bit taler
Timing/ruatments
How often and at what times 00 you wake up at night?
It vanes. I don't shways look at the clock and I haven't been keeping oxtailed track of how offert.
Tuning/Treatments
How often do you have insomnia?
I never had this problem until recandy
Timing/Treatment
What has worked for your insomnia and what has not?
I have tried a glass of milk, but it does not work. I have never had this problem before. I just don't understand what is different was an happy to be retired I have no pramaure. V just don't understand what is going on.
Seventy
HP
How much weight have you lost?
can't remember what the nurse said. Can you check my chart
PMH, FH, SH as Needed
Asked X Not asked
Graded Approach Question
FMH
Are you taking any medications that were prescribed by a different health care provider?
Response
Un
Information Obtained Clinie Notes
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