Mental Health and Sleep History Form

General Information

First Name

Last Name

Phone *

Email *

Presenting Sleep Concerns

What is your primary sleep concern? (e.g., difficulty falling asleep, excessive daytime sleepiness, frequent awakenings, nightmares, restless sleep) Please describe your main sleep-related issue in detail.

How long have you been experiencing these sleep issues? (e.g., weeks, months, years)

How has your sleep issue affected your daily life? (e.g., work performance, social interactions, mood, concentration, memory, or overall well-being)

Sleep-Wake Schedule

Weekday bedtime:

Weekday wake-up time:

Weekend bedtime:

Weekend wake-up time:

Sleep onset latency (time to fall asleep):

Night awakenings (frequency & duration):

Total sleep duration: Hours Per Night:

Naps (frequency, duration, and time of day):

Sleep Quality & Patterns

How well do you sleep?

Do you wake up refreshed?

Do you experience daytime Sleepiness?

If yes, how many hours per day are you sleeping?

Do you have Dreams/Nightmares?

Sleep Environment & Hygiene

Please describe your room environment

What electronic devices are used before bed?

Please provide time usage on these

Do you consume caffeine, alcohol, or nicotine before bedtime? If yes, please provide examples (e.g., coffee, tea, energy drinks, wine, beer, cigarettes, vaping).

Can you describe your bedtime routine in detail? Please include any activities you do before sleep, such as reading, watching TV, using electronic devices, relaxation techniques, skincare routines, or any other habits. Also, mention the approximate time you start winding down and how these activities impact your sleep quality.

Medical & Psychiatric History

Have you been diagnosed with any sleep disorders? If yes, please specify (e.g., insomnia, sleep apnea, narcolepsy, restless legs syndrome, hypersomnia, parasomnias, circadian rhythm disorders). If applicable, please include when you were diagnosed and any treatments or interventions you are currently receiving.

Do you have any existing medical conditions? If yes, please specify (e.g., chronic pain, asthma, diabetes, neurological conditions, heart disease, gastrointestinal disorders). Additionally, please describe how these conditions may impact your sleep quality or contribute to sleep disturbances.

Do you have any diagnosed or suspected mental health conditions? If yes, please specify (e.g., ADHD, anxiety, depression, PTSD, bipolar disorder, OCD).

Are you currently taking any medications that may affect your sleep? If yes, please list them along with their effects on your sleep (e.g., sedating, stimulating, causing vivid dreams, increasing night awakenings). Include both prescription and over-the-counter medications, as well as any supplements or herbal remedies.

Family & Lifestyle Factors

Is there a family history of sleep disorders? (Yes/No) If yes, please specify which sleep disorders are present in your family (e.g., insomnia, sleep apnea, narcolepsy, restless legs syndrome) and which family members have been affected (e.g., parent, sibling, grandparent).

What is your current work schedule? Please specify whether you work daytime shifts, rotating shifts, night shifts, or irregular hours. If applicable, describe how your work schedule affects your sleep patterns and overall sleep quality.

How would you describe your level of physical activity? Please specify whether you engage in daily exercise, occasional physical activity, or lead a mostly sedentary lifestyle. Additionally, mention the types of activities you participate in and whether you engage in exercise close to bedtime.

Previous Sleep Interventions & Strategies Tried

What sleeping methods have you used?

What was the outcome, Did they work? Was these affective? Are you still using them?

Have you used any sleep aids or medications? Currently using or in the past?

Please list the medication dosage.

Have you sought professional support for your sleep issues, Currently or in the past?

Are you currently using any sleep improvement strategies?

Sensory sensitivities that affect your sleep

Visual (Sight): Do bright lights, blinking LEDs, or changes in lighting affect your ability to sleep?

Please provide examples.

Auditory (Hearing): Are you sensitive to noises such as ticking clocks, traffic sounds, or sudden noises? Do you require white noise or silence to sleep?

Please provide examples

Tactile (Touch): Do you find certain fabrics, clothing, or bedding uncomfortable? Are you sensitive to temperature changes or the feeling of blankets?

Please provide examples

Olfactory (Smell): Are strong scents (e.g., perfumes, candles, cleaning products) disruptive to your sleep? Do you need certain smells (e.g., lavender, essential oils) to relax?

Please provide examples

Gustatory (Taste): Do certain food or drink textures or aftertastes impact your ability to fall asleep? Do you avoid eating before bed due to sensory discomfort?

Please provide examples

Vestibular (Balance & Movement): Do you feel discomfort with certain sleeping positions? Do movements such as rolling over, shifting, or a rocking sensation affect your ability to stay asleep?

Please provide examples

Proprioceptive (Body Awareness): Do you struggle with feeling "restless" in bed? Do you need deep pressure (e.g., weighted blankets) to feel comfortable?

Please provide examples

Interception (Internal Body Signals): Are you highly aware of bodily sensations like heart rate, breathing, or digestion, making it harder to relax and sleep?

Please provide examples

Incontinence & Sleep

Incontinence and sleep refers to the involuntary loss of urine or bowel control during sleep

Do you experience incontinence during sleep, and how often does it occur? (e.g., nightly, a few times a week, occasionally)

How does incontinence impact your sleep quality? (e.g., frequent awakenings, difficulty falling back asleep, anxiety about accidents)

What strategies or protective measures do you currently use to manage nighttime incontinence? (e.g., incontinence pads, bed protectors, limiting fluids, setting alarms for bathroom trips)

Sleep Challenges Related to Attention, Restlessness, and Overactivity

Do you often struggle to quiet your mind at night, making it difficult to fall asleep? If so, what thoughts or distractions keep you awake?

Do you experience frequent tossing, turning, or physical restlessness in bed that makes it hard to settle into sleep?

Do you find it difficult to maintain a consistent sleep schedule or feel the urge to stay awake even when you know you should sleep? If so, what factors contribute to this?

Sleep Disruptions Related to Physical Discomfort and Past Experiences

Do you often wake up feeling uncomfortable or struggle to find a restful position during the night? If so, what helps or worsens this feeling?

Do certain memories, thoughts, or feelings surface at night that make it harder to relax and fall asleep?

Have you noticed any patterns where your sleep is more disturbed after stressful or physically demanding days?

Did your sleep patterns as a child differ from your current sleep habits? If so, were there any difficulties with falling asleep, staying asleep, or frequent night awakenings during childhood?

Is there anything else you would like to share or any other concerns or questions you would like us to address? Please include anything you feel may be relevant or helpful in understanding and improving your sleep.

Disclaimer

By completing this form, you confirm that the information provided is true and accurate to the best of your knowledge. This information will be used to support your sleep assessment and treatment plan. By entering the date in the box provided, you acknowledge and accept this as your electronic signature, confirming your agreement to the accuracy of the details submitted.

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