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Sleep History Form Ellen C. Friedman, LPC, RP SGT! Name Date of birth Age Race/Ethnicity: Name of Referring Physician: ! Marital Status: (circle) Never married Partnered Separated Divorced Widowed
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How to fill out sleep history form
How to fill out sleep history form
01
Start by analyzing your sleep patterns for the past few weeks.
02
Note down the time you go to bed and the time you wake up each day.
03
Record any interruptions or disturbances during your sleep, such as waking up in the middle of the night or difficulty falling asleep.
04
Keep track of the quality of your sleep, rating it on a scale from 1 to 10.
05
Note any factors that may have influenced your sleep, such as caffeine or alcohol consumption, medication, or stressful events.
06
Be specific about any sleep disorders or conditions you may have been diagnosed with, and mention any treatments or medications you are currently taking.
07
Finally, summarize your overall sleep experience and any additional observations or comments you may have.
Who needs sleep history form?
01
Sleep history forms are typically used by medical professionals, sleep specialists, or researchers to gather detailed information about an individual's sleep patterns and habits.
02
It can be beneficial for individuals who are experiencing sleep problems or disorders and want to seek professional help.
03
Sleep history forms can also be used in sleep studies or research studies to collect data and analyze sleep patterns on a larger scale.
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