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

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

Information Obtained Clinie Notes