SHADOW HEALTH NICOLE
DIAZ- PTSD
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
, Comprehensive Sleep and Mental Health Assessment
1. Chief Complaint
1. Reports chronic sleep problems (10+ years duration)
2. Frequency: Most nights weekly
2. Sleep Characteristics
3. Nightmares reported
4. Prolonged sleep latency (>1 hour)
5. Frequent nighttime awakenings (2-3x/night for ≥10 minutes)
6. Non-restorative sleep ("waking feeling out of it")
7. Loud snoring reported
8. Average total sleep: 4-5 hours/night
3. Sleep Habits
9. Bedtime routine:
o Attempts sleep at midnight
o Actual sleep onset 2-3am
o Security checks (windows/doors 2x)
10. Sleep environment:
o Dark/quiet room
o No screen use before bed
o Sleeps alone
11. Wake time: 7am consistently
4. Exacerbating Factors
12. Stress/anxiety worsen sleep
13. PTSD-related hypervigilance
5. Medical History
14. Hypertension:
o Diagnosed age 45
o Current medication: Losartan 100mg daily
DIAZ- PTSD
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
, Comprehensive Sleep and Mental Health Assessment
1. Chief Complaint
1. Reports chronic sleep problems (10+ years duration)
2. Frequency: Most nights weekly
2. Sleep Characteristics
3. Nightmares reported
4. Prolonged sleep latency (>1 hour)
5. Frequent nighttime awakenings (2-3x/night for ≥10 minutes)
6. Non-restorative sleep ("waking feeling out of it")
7. Loud snoring reported
8. Average total sleep: 4-5 hours/night
3. Sleep Habits
9. Bedtime routine:
o Attempts sleep at midnight
o Actual sleep onset 2-3am
o Security checks (windows/doors 2x)
10. Sleep environment:
o Dark/quiet room
o No screen use before bed
o Sleeps alone
11. Wake time: 7am consistently
4. Exacerbating Factors
12. Stress/anxiety worsen sleep
13. PTSD-related hypervigilance
5. Medical History
14. Hypertension:
o Diagnosed age 45
o Current medication: Losartan 100mg daily
