ShadowHealth Mental Health Tina Jones With Complete
Solution
what brings you in today
Reports difficulty sleeping and "feeling nervous"
Why did you decide to seek treatment?
Reports seeking treatment because she has an upcoming exam and feels "too foggy to
study"
how do you feel just before bed
reports excessive worry and racing thoughts before bed
"I'm sorry to hear about your trouble sleeping and stress. I'm glad you came in. Let me
learn more about what you're experiencing, and I will try to help."
Tina describes problems sleeping and stress-symptoms like racing thoughts.
how long have you been having trouble sleeping
Reports difficulty sleeping began 3 1/2 weeks ago
how long have your sleep difficulties lasted
reports sleep difficulties have been occurring regularly past 3.5 weeks
how many nights a week do you have trouble sleeping
reports difficulty sleeping at least four or five times a week
what makes it harder to sleep
reports sleeping becomes more difficult when she can not redirect her thoughts from the
things she is worried about
do you take naps
denies naps during the day
do you drink caffeine
reports drinking caffeine to stay alert
when do you usually have your last caffeinated drink
reports stopping caffeine use after 4 pm
do you drink alcohol before bed
denies alcohol use before bed
do you use drugs before bed
denies drug use before bed
do you think your sleep problems could be due to breathing issues
reports respiratory problems are controlled and not interfering with sleep
what helps you sleep
reports sleeping more easily if she can distract herself from her racing thoughts
do you exercise
reports no exercise
how does your lack of sleep affect your daily life
reports feeling tired and out of it most of the time during the day due to lack of sleep
have you been falling asleep when you didnt mean to
reports no increased chance of drifting off during the day despite lack of sleep
what do you mean when you say you feel out of it
reports feeling slowed down and tired, having trouble focusing, and generally feeling
less sharp
, can you tell me about how your anxiety feels
reports feelings of anxiety as thoughts she cant turn off and being on edge
do you ever have a sense of impending doom
reports worry about the future but no sense of impending doom
have you been having panic attacks
reports no panic attacks
have you been having trouble concentrating
reports difficulty concentrating due to fatigue from lack of sleep
do you feel restless
reports only restlessness occurs just before bed
do you feel irritable
reports slight irritability due to fatigue
how does your anxiety interfere with your daily life
reports stress only interferes with daily life because it interrupts her sleep
how often do you awaken during the night
reports waking up two or three times during the night for at least 10 minutes
how do you feel when you wake up in the morning
reports waking in the morning feeling out of it and not rested
when do you go to bed
reports going to bed around midnight but feeling too nervous to sleep
when do you fall asleep
reports actually falling asleep at 2 or 3 am
what do you usually do before bed
reports reading before bed
do you watch tv or use the computer before bed
reports no screen time before bed
when do you usually wake up
reports average wake time of 8 am
how many hours a night do you sleep
reports sleeping an average of 4-5 hours a night
"It's hard to function at our best when we don't get enough sleep. I know you're very
busy with work and school, but let's talk about some strategies to help you get more
sleep and make sure you're getting good quality sleep."
Tina describes her sleep hygiene and routine.
can you describe where you sleep
reports sleeping alone in a quiet room
how do you feel when you're stressed
reports feeling nervous and worrying about the future with racing thoughts
are you taking any new medications
confirms medications
have you been taking OTC meds to help you sleep
denies taking OTC sleep meds
have you taken prescription medications to help you sleep
denies taking prescription sleep medications
have you had any new allergies
confirms allergies
Solution
what brings you in today
Reports difficulty sleeping and "feeling nervous"
Why did you decide to seek treatment?
Reports seeking treatment because she has an upcoming exam and feels "too foggy to
study"
how do you feel just before bed
reports excessive worry and racing thoughts before bed
"I'm sorry to hear about your trouble sleeping and stress. I'm glad you came in. Let me
learn more about what you're experiencing, and I will try to help."
Tina describes problems sleeping and stress-symptoms like racing thoughts.
how long have you been having trouble sleeping
Reports difficulty sleeping began 3 1/2 weeks ago
how long have your sleep difficulties lasted
reports sleep difficulties have been occurring regularly past 3.5 weeks
how many nights a week do you have trouble sleeping
reports difficulty sleeping at least four or five times a week
what makes it harder to sleep
reports sleeping becomes more difficult when she can not redirect her thoughts from the
things she is worried about
do you take naps
denies naps during the day
do you drink caffeine
reports drinking caffeine to stay alert
when do you usually have your last caffeinated drink
reports stopping caffeine use after 4 pm
do you drink alcohol before bed
denies alcohol use before bed
do you use drugs before bed
denies drug use before bed
do you think your sleep problems could be due to breathing issues
reports respiratory problems are controlled and not interfering with sleep
what helps you sleep
reports sleeping more easily if she can distract herself from her racing thoughts
do you exercise
reports no exercise
how does your lack of sleep affect your daily life
reports feeling tired and out of it most of the time during the day due to lack of sleep
have you been falling asleep when you didnt mean to
reports no increased chance of drifting off during the day despite lack of sleep
what do you mean when you say you feel out of it
reports feeling slowed down and tired, having trouble focusing, and generally feeling
less sharp
, can you tell me about how your anxiety feels
reports feelings of anxiety as thoughts she cant turn off and being on edge
do you ever have a sense of impending doom
reports worry about the future but no sense of impending doom
have you been having panic attacks
reports no panic attacks
have you been having trouble concentrating
reports difficulty concentrating due to fatigue from lack of sleep
do you feel restless
reports only restlessness occurs just before bed
do you feel irritable
reports slight irritability due to fatigue
how does your anxiety interfere with your daily life
reports stress only interferes with daily life because it interrupts her sleep
how often do you awaken during the night
reports waking up two or three times during the night for at least 10 minutes
how do you feel when you wake up in the morning
reports waking in the morning feeling out of it and not rested
when do you go to bed
reports going to bed around midnight but feeling too nervous to sleep
when do you fall asleep
reports actually falling asleep at 2 or 3 am
what do you usually do before bed
reports reading before bed
do you watch tv or use the computer before bed
reports no screen time before bed
when do you usually wake up
reports average wake time of 8 am
how many hours a night do you sleep
reports sleeping an average of 4-5 hours a night
"It's hard to function at our best when we don't get enough sleep. I know you're very
busy with work and school, but let's talk about some strategies to help you get more
sleep and make sure you're getting good quality sleep."
Tina describes her sleep hygiene and routine.
can you describe where you sleep
reports sleeping alone in a quiet room
how do you feel when you're stressed
reports feeling nervous and worrying about the future with racing thoughts
are you taking any new medications
confirms medications
have you been taking OTC meds to help you sleep
denies taking OTC sleep meds
have you taken prescription medications to help you sleep
denies taking prescription sleep medications
have you had any new allergies
confirms allergies
