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INSOMNIA HISTORY
1. Has your CURRENT insomnia been going on for less than 3 months (or more than 3 months)?
Yes
No
2. How long does it typically take you to fall asleep :
Choose...
0-15 minutes
15-30 minutes
Longer than 30 minutes
3. How many times do you awake throughout the night (for more than 15 minutes)?
4. How many minutes does it take for you to fall back asleep?
5. How many total hours of sleep per night do you typically get?
6. During each 24 hour cycle, do you consistently sleep during the same “time block” (such as the time block from 11.00pm until 7.00am, for example)?
Yes
No
If Answere is No:
6.1 what is your typical pattern of “time blocks” when you sleep?
7. How is your daily performance affected by your insomnia, if at all (concentration problems, etc)?
8. Do you have sleepiness during your awake “time blocks” (such as 7.00am until 11.00pm, or whenever that time block is for you)?
9. Do your arms or legs move around (by themselves) while you are asleep?
10. Are you a restless sleeper (or do you find the bedsheets in disarray when you wake up)?
11. Do you have a weird feeling in your legs (when laying in bed) that makes you want to move them? If YES, then when you move them does that relieve the feeling, at least for a while?
Yes
No
12. What is the number of alcoholic drinks you typically consume (on nights you choose to drink)? What is the number of nights per week that you typically choose to drink alcohol?
13. Do you take any opiate (opioid) pain medication at night (ex: codeine; hydrocodone; morphine; etc)? If YES, is that because of a chronic pain condition?
14. Do you take any prescription OR over the counter medications to help you sleep?
Yes
No
If Yes
14.1 Which One?
14.2 What is the number of nights per week you typically take these?
14.3 What is the number of months (or years) you have been taking these?
15. Are there any other medications you take at night that have sedating effects (ex: muscle relaxers; benadryl/diphenhydramine or other allergy meds; etc)?
Yes
No
If Yes
15.1 What is the number of months (or years) you have been taking these ?
16. Have you ever done anything like sleep walking (or other sleep activities) after having taken any of the medications above?
Yes
No
If YES
16.1 which medication had you taken earlier that night ?
17. Do any of the above medications ever cause a residual hangover effect the next morning?
Yes
No
If YES
17.1 which medication had you taken earlier that night ?
18. The next day after taking any of the above medications, have you ever not remembered a portion of the day?
Yes
No
If YES
18.1. which medication had you taken earlier that night ?
19. Do you ever take more than one of the above medications (or alcohol) in the same night?
20. If you were to skip a dose of any of the above medications tonight, is the insomnia you would have tonight WORSE than the insomnia you had prior to ever taking the medication?
21. For MANY years have you consistently (EVERY night) had trouble falling asleep before midnight or even before 6.00am?
Yes
No
If YES, then please answer these questions:
21.1 At what age did this issue begin?
21.2 Since that age, what is the time you are unable to fall asleep prior to (midnight? 6.00am?)
21.3 If you take sleeping pills, that will muddy the water regarding this issue
21.4 So if you take sleeping pills, at what age did you start taking sleeping pills?
21.5 Do you work a night shift (ex: 10pm until 6am) or alternate between night and day shifts?
Yes
No
21.6 Do you take naps for longer than 30 minutes?
Yes
No
21.7 Do you have caffeine after 3:00pm (or even after 12 noon)?
Yes
No
21.8 Do you have alcohol w/in 4-6 hours of your bedtime?
Yes
No
21.9 Do you use THC (marijuana) or any other drugs?
Yes
No
21.10 Do you have bladder problems, or ADD (or ADHD), or a diagnosis of anxiety or depression?
Yes
No
