SLEEP MEDICINE CONSULT NOTE

Patient: [Name, age, sex]
Date of visit: [Date]
Visit type: [New consult or follow-up; in person or video]
Referred by: [Name and specialty; bed partner present or not]
Sleep physician: [Name, credentials]

REFERRAL QUESTION
Question asked: [What the referrer wants answered, in their words]
Main complaint: [The patient's concern, in their words]
Onset and course: [When it started, what set it off, and how it has changed]

SLEEP SCHEDULE
Work days: [In bed, minutes to fall asleep, night wakings, final waking, out of bed]
Free days: [The same times on days off]
Sleep against time in bed: [Hours asleep, hours in bed, naps]
Routine: [Shift or night work, morning or evening type, screens, caffeine, alcohol, exercise timing]

SNORING AND BREATHING
Snoring: [Loudness, nights a week, any link to position]
Witnessed events: [Pauses, choking or gasping, waking short of breath]
Related symptoms: [Morning headache, dry mouth, night-time urination, reflux, nasal blockage]
STOP-Bang: [Total out of 8, and the items that scored]

SLEEPINESS AND DRIVING
Epworth Sleepiness Scale: [Total out of 24, and its range]
Sleepiness or fatigue: [Dozes without meaning to, or tired without dozing]
Narcolepsy features: [Cataplexy, sleep paralysis, hallucinations at sleep onset or waking, or none]
Driving and work: [What and how much the patient drives; drowsy episodes, near misses, crashes; safety-sensitive work]

INSOMNIA
Pattern: [Trouble falling asleep, staying asleep, or early waking; nights a week; how many months]
Insomnia Severity Index: [Total out of 28, and its range]
What keeps it going: [Time awake in bed, clock-watching, naps, sleeping in, worry about sleep]
Sleep aids tried: [Prescription, over-the-counter, melatonin, alcohol, cannabis, and the effect of each]

LEGS AND BEHAVIORS IN SLEEP
Restless legs: [Urge to move the legs, worse at rest and in the evening, eased by moving; ferritin and transferrin saturation if present; or none]
Behaviors: [Sleepwalking, night terrors, dream enactment, injuries, teeth grinding, limb jerks, or none]

HISTORY AND MEDICINES
Medical: [Hypertension, heart failure, atrial fibrillation, stroke, lung disease, neuromuscular disease, chronic pain, thyroid disease]
Mental health: [Mood, anxiety, bipolar disorder, PTSD; screening scores]
Medicines: [Sedating, stimulating, or sleep-altering medicines and their timing; opioids]
Substances: [Caffeine, alcohol, cannabis, nicotine, other drugs]
Family history: [Sleep apnea, restless legs, narcolepsy, or none]

EXAMINATION
Vitals and size: [Blood pressure, heart rate, weight, height, BMI]
Neck: [Circumference in cm]
Upper airway: [Nasal patency, Mallampati class, tonsil grade, palate, jaw position]
Other: [Heart, lungs, leg edema, neurological findings that matter]

ASSESSMENT AND TEST CHOICE
Working diagnoses: [Each sleep diagnosis, with the findings behind it]
Contributing factors: [Short sleep, weight, alcohol, medicines, mood, pain]
Test: [Home sleep apnea test, in-lab polysomnogram, split-night study, MSLT, actigraphy, sleep diary, or none]
Why this test: [Why it fits the patient, or why no test is needed; routine or expedited]

PLAN
Treatment: [CPAP, oral appliance, positional therapy, CBT-I, weight management, iron, or other]
Medicines: [Started, stopped, or deliberately not started, with the reason]
Driving and safety: [Advice given, any reporting duty considered under the rules where you practice, and the patient's response]
Follow-up: [Results visit, device download, or CBT-I review, with dates; copies to the referrer]

Signed: [Sleep physician name, credentials, date and time]