| RPT |
.| .| Dysfunctional Beliefs and Attitudes about Sleep| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN:
<*Answer_6599*>| 12. When I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before.| <*Answer_6600*>| 13. I
believe insomnia is essentially the result of a chemical imbalance.| <*Answer_6601*>| 14. I feel insomnia is ruining my ability to enjoy life and prevents me from doing what I want.|
<*Answer_6602*>| 15. Medication is probably the only solution to sleeplessness.| <*Answer_6603*>| 16. I avoid or cancel obligations (social, family) after a poor nights sleep.|
<*Answer_6604*>| | (c) Copyright: Monin, C. 1993| | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment
results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~
<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | <.DLL_String.>| | The score is the average of the answered items. A high score indicates a belief
that sleep disruption is maladaptive.| | | Questions and Answers| | 1. I need 8 hours of sleep to feel refreshed and function well during the day.| <*Answer_6589*>| 2. When I don't get proper
amount of sleep on a given night, I need to catch up on the next day by napping or on the next night by sleeping longer.| <*Answer_6590*>| 3. I am concerned that chronic insomnia may have serious
consequences on my physical health.| <*Answer_6591*>| 4. I am worried that I may lose control over my abilities to sleep.| <*Answer_6592*>| 5. After a poor nights sleep, I know that it will
interfere with my daily activities on the next day.| <*Answer_6593*>| 6. In order to be alert and function well during the day, I believe I would be better off taking a sleeping pill rather than
having a poor nights sleep.| <*Answer_6594*>| 7. When I feel irritable, depressed, or anxious during the day, it is mostly because I did not sleep well the night before.| <*Answer_6595*>| 8.
When I sleep poorly on one night, I know it will disturb my sleep schedule for the whole week.| <*Answer_6596*>| 9. Without an adequate nights sleep, I can hardly function the next day.|
<*Answer_6597*>| 10. I cant ever predict whether Ill have a good or poor nights sleep.| <*Answer_6598*>| 11. I have little ability to manage the negative consequences of disturbed sleep.|
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