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Sleep History
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Difficulty falling asleep?
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Comments
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Difficulty staying asleep?
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Comments
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Problems waking up early?
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Comments
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Does you sleep problem INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability
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Berlin Sleep Questionnaire
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Sleep Category 1
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1. Do you snore?
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2. If ‘yes’: Your snoring is:
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3. How often do you snore?
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4. bothered other people?
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5. stop breathing during sleep
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Sleep Category 2
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6. How often feel tired waking up?
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7. Tired during the day?
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8. Fall asleep while driving?
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If yes, how often does it occur?
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Sleep Category 3
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Any of the following conditions?
• • •
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Scoring Categories: 2 or more positive categories indicates a high likelihood of sleep disordered breathing
• • •
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High likelihood of sleep disordered breathing
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Hours of sleep nightly
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Prior Sleep Study
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Past Studies
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DSM 5 Insomnia Checklist
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Symptoms
• • •
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Symptoms>3 months
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Comments
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Symptoms are
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Comments
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Impacts Daily Function?
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Comments
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> 3 times per week
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Comments
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Has time to sleep?
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Comments
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Not Due to Other Sleep Disorder ?
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Comments
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Not Due to Other Mental/Medical Disorder
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Comments
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Not due to meds or drugs?
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Comments
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(Yes to All) - Meets DSM-5
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Plan
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Does not meet Criteria
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Plan
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