Sleep Medicine Initial Consultation Note (Comprehensive Sleep Evaluation)

Encounter date and time: [Date and time of encounter]

Location and visit modality: [Clinic location]; [in-person / video]

Rendering clinician: [Clinician name, credentials]

Referring clinician: [Name, specialty, practice]

Reason for referral: [Referral indication] (Include verbatim referral text when available)

Primary language and interpreter use: [Primary language]; Interpreter [used / not used]; [Interpreter modality and ID if used]

Chief Complaint

[Patient's stated sleep concern in 1–2 sentences] (May include a brief direct quote. If referral-driven: "Referred for evaluation of [indication].")

History of Present Illness

[Chronological narrative beginning with why the patient is presenting now, including onset, course, recent changes, and relevant triggers such as weight change, new medications, shift work, or life events. Continue with current severity and functional impact including daytime impairment, near-misses or accidents, and work or school performance effects. Include prior sleep evaluations and treatments with response, and patient goals and preferences for workup.] (Write as 2–4 flowing paragraphs integrating relevant symptom domains: snoring and witnessed apneas, excessive daytime sleepiness versus fatigue, insomnia symptoms, abnormal nocturnal behaviors, leg restlessness, and schedule or circadian concerns. Do not infer symptoms not explicitly obtained from the patient.)

Comprehensive Sleep History

Sleep Schedule

• Usual bedtime: [Time] (Note weekday vs weekend variability)
• Sleep onset latency: [Minutes]
• Nocturnal awakenings: [Number and duration]; Time to return to sleep: [Minutes]
• Final wake time: [Time]; Out of bed: [Time]
• Estimated total sleep time: [Hours]
• Perceived sleep quality: [poor / fair / good / very good]
• Naps: [Frequency, duration, timing, whether refreshing]
• Shift work: [none / rotating / fixed night / other] (Include pattern if applicable)
• Sleep environment: [Bed partner, pets, noise, light, electronics, other factors]

(If patient cannot provide estimates, document: "Unable to estimate; sleep diary to be obtained.")

Sleep-Disordered Breathing Symptoms

• Loud habitual snoring: [present / absent / uncertain]
• Witnessed apneas: [present / absent / uncertain]
• Gasping or choking arousals: [present / absent / uncertain]
• Morning headaches: [present / absent]
• Dry mouth on awakening: [present / absent]
• Nocturia: [present / absent]
• Nocturnal reflux: [present / absent]
• Positional component: [worse supine / lateral / unknown]
• Nasal obstruction: [present / absent]
• Weight trajectory: [gain / stable / loss] over [Timeframe]

Excessive Daytime Sleepiness

• Patient description: [Sleepiness vs fatigue in patient's words]
• Unintentional dozing: [Situations and frequency]
• Sleep attacks: [present / absent]
• Morning sleep inertia or sleep drunkenness: [present / absent]
• Cataplexy (emotion-triggered weakness): [present / absent / uncertain]
• Sleep paralysis: [present / absent]
• Hypnagogic/hypnopompic hallucinations: [present / absent]
• Automatic behaviors: [present / absent]
• Safety-sensitive duties (driving, machinery): [yes / no] (Describe if yes)

Insomnia Features

• Type: [sleep-onset / maintenance / early morning awakening / mixed]
• Frequency and duration: [Nights per week; duration in weeks/months/years]
• Precipitating and perpetuating factors: [List]
• Daytime consequences: [Fatigue, cognitive issues, mood changes, performance impact]
• Conditioned behaviors: [List]
• Prior treatments: [CBT-I / hypnotics / other] with response: [effective / partial / ineffective / adverse effects]

Circadian and Schedule Factors

• Desired vs actual sleep schedule: [Describe mismatch if present]
• Weekday–weekend variability: [minimal / moderate / marked]
• Light exposure habits: [Morning, evening, screen use timing]
• Prior melatonin or light therapy: [used / not used]; [Dose/timing]; Response: [benefit / none / adverse]

Parasomnia Screening

• Dream enactment (punching, kicking, vocalizations with dream recall): [present / absent / uncertain]
• NREM events (sleepwalking, confusional arousals, sleep terrors): [present / absent / uncertain]
• Nightmares: [present / absent]
• Bruxism: [present / absent]
• Injuries to patient or bed partner: [yes / no] (Describe if yes)
• Triggers: [Sleep deprivation, alcohol, medications, or none identified]

Restless Legs

• Urge to move legs with discomfort: [present / absent / uncertain]
• Worse at rest: [yes / no]
• Relieved by movement: [yes / no]
• Worse in evening or night: [yes / no]
• Mimics considered: [Features supporting or against leg cramps, neuropathy, arthritis, positional discomfort]
• Contributing factors: [Iron deficiency history, pregnancy, kidney disease, medications, or none]

Validated Instruments

(Include only if questionnaires were administered during this encounter. Do not use scores alone as diagnostic criteria.)

• [Instrument name]: Score [#]/[Scale]; Date: [Date]; Completed by: [patient / caregiver / clinician]

Prior Sleep Testing and Treatments

• Prior sleep studies: [PSG / HSAT]; Date: [Date]; AHI: [Value]; Oxygen nadir: [Value]; [Positional/REM effects] (If unavailable: "Patient reports prior sleep study; records requested.")
• PAP therapy: Device: [Type]; Mask: [Type]; Settings: [Pressures/mode]; Adherence: [Hours/night]; Benefit: [yes / no / partial]; Side effects: [List]
• Other treatments: [Oral appliance / positional therapy / weight intervention / ENT surgery / CBT-I / hypnotics] with response: [benefit / partial / none / adverse]

Past Medical History

(Emphasize conditions affecting sleep and test selection.)

• Cardiopulmonary: [Heart failure, COPD, pulmonary hypertension, or none]
• Neurologic: [Stroke, neuromuscular disease, neurodegenerative disease, or none]
• Metabolic/endocrine: [Obesity, diabetes, hypothyroidism, or none]
• Psychiatric: [Depression, anxiety, PTSD, or none]
• Other relevant conditions: [Chronic pain, GERD, chronic rhinitis, craniofacial abnormalities, prior airway surgery]

Medications and Substances

Medications

(List current medications with dose and timing. Explicitly capture sleep-relevant agents.)

• Opioids: [Agent, total daily dose, schedule]
• Benzodiazepines/Z-drugs: [Agent, dose, timing]
• Sedating antidepressants/antipsychotics: [Agent, dose, timing]
• Stimulants/wake-promoting agents: [Agent, dose, timing]
• SSRIs/SNRIs: [Agent, dose, timing]
• Gabapentinoids: [Agent, dose, timing]
• Melatonin: [Dose, timing]
• Other: [Agent, dose, timing]

Substances

• Caffeine: [Amount per day]; Last intake: [Time]
• Alcohol: [Quantity and frequency]; Timing: [Relative to bedtime]; Used as sleep aid: [yes / no]
• Nicotine: [Type, amount, timing]
• Cannabis: [Form, timing]

(If timing unclear: "Timing to be clarified prior to objective testing.")

Allergies

• [Drug/agent]: [Reaction]; Severity: [mild / moderate / severe]

(Note sedative-hypnotic reactions, paradoxical reactions, and adhesive sensitivity if present.)

Family History

• Obstructive sleep apnea: [present / absent / unknown]
• Sudden cardiac death: [present / absent / unknown]
• Restless legs syndrome: [present / absent / unknown]
• Narcolepsy: [present / absent / unknown]
• Parasomnias: [present / absent / unknown]
• Neurodegenerative disease: [present / absent / unknown] (Document if dream enactment present)

Social History

• Occupation and schedule: [Role, schedule, commute]
• Caregiving responsibilities: [Details or none]
• Exercise patterns: [Type, frequency, timing]
• Environmental constraints on sleep: [Details or none]

Review of Systems

(Targeted review of sleep-relevant systems. Document pertinent positives and negatives.)

• ENT: [Nasal obstruction, mouth breathing]
• Cardiovascular: [Palpitations, edema]
• Pulmonary: [Dyspnea, wheeze]
• Neurologic: [Headaches, weakness, tremor, cognitive changes]
• Psychiatric: [Depression, anxiety, PTSD symptoms]

Physical Examination

Vitals

• Blood pressure: [Value]
• Heart rate: [Value]
• BMI: [Value]
• Neck circumference: [cm] (If measured)
• Resting SpO2: [%] (If available)

Examination by System

• HEENT/Upper airway: [Nasal patency, septal deviation, turbinates, tonsillar size, tongue size, Mallampati score, jaw position/retrognathia]
• Cardiovascular: [Rhythm, murmurs, edema]
• Pulmonary: [Effort, breath sounds]
• Neurologic: [Orientation, cranial nerves, motor/tone, gait] (Include when parasomnia or hypersomnolence features present)
• Extremities: [Edema, other findings]

Data Reviewed

(List external data sources reviewed. Include only items actually reviewed.)

• Prior sleep study reports: [Dates, key findings]
• PAP download data: [Date range, adherence, residual AHI, leak]
• Outside medical records: [Source, pertinent details]
• Laboratory results: [Ferritin, TSH, others if relevant]
• Imaging: [Type, date, key findings]

Safety Assessment and Counseling

(Required when excessive daytime sleepiness, parasomnia, or sedating medications are present.)

Drowsy Driving and Occupational Safety

• Drowsy driving, near-crashes, or falling asleep at the wheel: [yes / no] (Describe if yes)
• Safety-sensitive occupational duties: [yes / no] (Describe if yes)
• Counseling provided: [Advised to avoid driving when sleepy, pull over if drowsy, arrange alternative transportation] (Document patient response and any work restrictions with rationale)

Parasomnia Safety

• Injurious nocturnal behaviors or falls: [yes / no] (Describe if yes)
• Weapons accessibility: [yes / no]
• Environmental modifications discussed: [Remove sharp objects, pad furniture, floor mats, separate sleeping arrangements, lock doors/windows]

(If no safety concerns: "No drowsy driving or occupational safety concerns. No injurious nocturnal behaviors reported.")

Assessment

(Problem-oriented synthesis ordered by clinical priority and safety. Do not diagnose OSA without objective testing; document as "suspected OSA" or "high clinical suspicion for OSA.")

[Problem 1]

• Key supporting findings: [Symptoms, exam, prior data]
• Severity and safety risks: [Description]
• Differential diagnosis: [List if uncertain]

[Problem 2]

• Key supporting findings: [Symptoms, exam, prior data]
• Severity and safety risks: [Description]
• Differential diagnosis: [List if uncertain]

Pretest probability for OSA: [low / moderate / high] based on [Supporting symptoms and comorbidities]. Patient is [uncomplicated / complicated] for home sleep testing. (Complicating conditions: significant cardiorespiratory disease, neuromuscular disease, hypoventilation syndrome, chronic opioid use, prior stroke, severe insomnia.)

Comorbidities supporting medical necessity: [Hypertension, ischemic heart disease, stroke history, excessive daytime sleepiness, impaired cognition, mood disturbance, insomnia] (List those present)

Plan

Sleep Study Recommendation and Rationale

• Study ordered: [HSAT / in-lab diagnostic PSG / split-night PSG / PAP titration / PSG with MSLT / actigraphy with sleep diary]
• Indication: [Symptoms, comorbidities, and safety considerations establishing medical necessity]
• HSAT justification (if applicable): Uncomplicated adult with high suspicion for moderate-to-severe OSA without significant cardiorespiratory disease, neuromuscular disease, hypoventilation, chronic opioid use, prior stroke, or severe insomnia. Contingency if negative/inconclusive/inadequate: proceed to in-lab PSG.
• PSG indication (if ordered instead of HSAT): [Complicating conditions, suspected diagnosis requiring EEG/additional channels, PAP titration need, or MSLT planning]

Treatment and Counseling by Problem

• Suspected sleep-disordered breathing: [Weight management counseling, avoid alcohol near bedtime, positional strategies, avoid sedatives, nasal care]
• Insomnia: [CBT-I referral or resource, medication consideration with shared decision-making]
• Restless legs: [Iron studies if indicated, medication review, pharmacotherapy consideration]
• Parasomnias: [Safety modifications, medication review, neurology referral if dream enactment raises concern]
• Hypersomnolence: [Optimize sleep opportunity, regularize schedule, medication washout plan for MSLT]

Referrals

• [ENT / dental sleep medicine / bariatric surgery / cardiology / behavioral sleep medicine / neurology]: [Reason]

Follow-Up

• Results communication: [Portal / phone / in-person]; Timeline: [Expected timeframe]
• Follow-up appointment: [Interval and modality]
• Instructions: Contact clinic if symptoms worsen or safety concerns arise before testing.