Insomnia Evaluation (CBT-I Intake)

Date: [Date of service]

Visit Type: Insomnia Evaluation (CBT-I Intake)

Provider: [Clinician name and credentials]

Collateral Sources: [Names and roles of bed partner, caregiver, or interpreter present] (Omit this line if none.)

Records Reviewed: [Prior sleep studies, labs, and relevant records with dates and key findings] (Omit this line if none.)

Chief Complaint

[Primary sleep concern in patient's own words; duration of problem; primary treatment goal] (Limit to one to two concise lines. Use quotation marks when directly quoting the patient.)

History of Present Illness

[Narrative synthesis of insomnia history including: onset and course (acute vs gradual, precipitating events or stressors); insomnia pattern (sleep-onset difficulty with estimated sleep onset latency, sleep maintenance difficulty with estimated wake after sleep onset, early-morning awakenings); adequacy of sleep opportunity and environment; daytime consequences (differentiate fatigue vs sleepiness, effects on concentration, mood, work performance, and safety); prior treatments (CBT-I, sleep hygiene, OTC agents, prescription sleep aids, supplements) with responses and barriers; patient beliefs about causes; worries or performance anxiety around sleep; specific goals for treatment] (If the patient cannot reliably estimate sleep latency or nocturnal wake time, note that these will be quantified via sleep diary.)

Sleep Schedule

• Weekday Schedule: [Bedtime]; [Lights-out time]; [Final wake time]; [Alarm used: yes / no]
• Weekend/Off-Day Schedule: [Bedtime]; [Lights-out time]; [Final wake time]; [Alarm used: yes / no] (Include only if different from weekdays.)
• Schedule Variability: [Degree of variability across days; quantify typical range if available]
• Naps: [Frequency]; [Typical duration]; [Timing]; [Intentional vs unintentional]
• Shift Work/Rotating Schedule: [Details of shift pattern and rotation] (Include only if applicable; otherwise omit.)

Sleep Environment and Behaviors

• Bedroom conditions: [Noise; light; temperature; evening screen exposure]
• Bed use for non-sleep activities: [TV; phone; work; eating in bed]
• Co-sleeping: [Partner, pets, or children; impact on patient's sleep]
• Caffeine: [Approximate amount and timing relative to bedtime]
• Alcohol: [Amount and timing relative to bedtime]
• Nicotine/cannabis/other substances: [Use and timing] (Omit if not relevant.)
• Evening routine: [Wind-down behaviors and timing]
• When unable to sleep: [Behaviors such as staying in bed awake, clock-watching, getting out of bed, relocating]

Baseline Measures

• ISI Score: [Numeric score] ([Date administered]) — [Brief interpretation, e.g., subthreshold / mild / moderate / severe clinical insomnia] (Include if administered.)
• Other instruments: [Instrument name; score; brief interpretation] (Include only if used, e.g., sleepiness scales, mood screens. Note that screening tools are not diagnostic.)
• Sleep Diary Status: [Initiated: yes / no]; [Format: paper / app]; [Planned monitoring period]; [Current adherence if underway]
• Baseline Diary Summary: [Average time in bed]; [Average total sleep time]; [Average sleep onset latency]; [Average wake after sleep onset]; [Sleep efficiency %] (Include only if baseline data available; otherwise note that baseline metrics will be calculated after diary completion.)

Differential Screening

• Obstructive sleep apnea: [Snoring; witnessed apneas; gasping; morning headaches; excessive daytime sleepiness; risk factors; screening tool score if used] (Brief statement; screening tools are not diagnostic.)
• Circadian rhythm: [Delayed or advanced phase patterns; social jet lag] (Include if relevant.)
• Restless legs syndrome: [Urge to move at rest; evening worsening; relief with movement] (Brief positives or negatives.)
• Parasomnias/nocturnal events: [Nightmares; sleepwalking; REM behavior symptoms] (Include if relevant.)

Medical and Psychiatric Contributors

[Pertinent medical conditions affecting sleep (e.g., chronic pain, GERD, pulmonary disease, nocturia with timing, thyroid disease, neurologic conditions) and psychiatric symptoms impacting sleep (anxiety, depression, PTSD, panic); current mental health treatment if relevant] (If mood symptoms are significant, document safety assessment performed and actions taken. Focus on sleep-relevant impacts rather than comprehensive medical history.)

Medications

• Current medications: [List with doses; note agents with activating or sedating effects]
• Sleep-related agents: [Name; dose; timing relative to bedtime; perceived benefit; concerns about tolerance or dependence] (Include prescription hypnotics, sedating antidepressants, antihistamines, melatonin, cannabis products.)

Objective Findings

• Vitals: [Vital signs] (Include if obtained.)
• Mental status observations: [Brief observations relevant to behavioral intake] (Include if relevant.)
• Prior sleep study data reviewed: [Type; date; key findings] (Include if reviewed.)

(If no physical exam or objective assessment performed, state: "No physical exam performed (behavioral intake).")

Assessment

Insomnia diagnosis: [Chronic / short-term] insomnia; [Severity impression, reference ISI score if available]; [Primary maintaining factors]

CBT-I case formulation (3P model): Predisposing: [Factors]. Precipitating: [Factors]. Perpetuating: [Factors targeted by treatment, e.g., excessive time in bed, irregular schedule, naps, conditioned arousal, sleep-related worry]

Differential considerations: [Suspected or excluded comorbid sleep disorders with rationale]

CBT-I appropriateness: [Appropriate to initiate now / Defer pending evaluation for suspected comorbid disorder]; [Safety considerations if applicable, e.g., safety-sensitive occupation, severe untreated sleepiness]

Plan

• CBT-I Education: [Discussed CBT-I rationale, expectations, and homework requirements; reviewed potential short-term adjustment effects during schedule changes]
• CBT-I Components Initiated: [Stimulus control instructions; sleep restriction or sleep compression; cognitive strategies for sleep-related worry; relaxation training; sleep hygiene as supportive education] (Specify which components start now vs planned for future sessions.)
• Sleep Diary Instructions: [Complete every morning; record bedtime, lights-out time, estimated sleep onset latency, number and duration of awakenings, final wake time, out-of-bed time, naps, alcohol/caffeine/medication use; monitoring duration (typically 1–2 weeks); diary will be used to calculate averages and set individualized sleep schedule]
• Sleep Window Prescription: [Prescribed wake time (anchor)]; [Prescribed time in bed (sleep window)]; [How determined (based on diary averages with appropriate safety floor)]; [Rules for adjustment at follow-up]; [Safety instructions regarding drowsy driving and when to contact clinic] (If baseline data insufficient, state that sleep window will be prescribed after diary completion and specify interim components initiated.)
• Workup and Referrals: [Testing plan if comorbid sleep disorder suspected—home sleep test, polysomnography, or referral]; [Labs ordered, e.g., ferritin for RLS]; [Specialty referrals]; [Hypnotic taper plan and coordination with prescriber] (Include only if applicable.)
• Follow-Up: [Follow-up interval (typically weekly early in CBT-I)]; [Items to review—sleep diary, adherence, barriers]; [Plan for repeating outcome measures]

(Omit sections or bullets that are not applicable. When information is pending, state what is pending and how it will be obtained. Do not infer diagnoses requiring objective testing; document clinical suspicion and testing plan instead.)