| RPT |
.| .| Sleep Need Questionnaire| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>|
DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | To determine what the next week's Total In Bed (TIB) should be, first calculate sleep efficiency (SE).|
| If SE is greater than or equal to 85% -- modify TIB according to the following scores on the Sleep Need Questionnaire:| (a) Score 9 or less - no change in TIB| (b) Score 10 to 12 - TIB is increased by 15
minutes for that week (and another 15 minutes for the following week, if you see the patient biweekly).| (c) Score 13 or more - TIB is increased by 30 minutes for that week (and another 30
minutes the following week, if you see the patient biweekly).| | If SE < 80% -- reduce TIB but only if the score on the Sleep Need Questionnaire: is 9 or less.| | Otherwise do not change TIB|
| | Sleep Need Questionnaire Score: <-SNQ->| | | Questions and Answers| | 1. Did you feel tired or fatigued during the day or evening?| <*Answer_6480*>| 2. Were you sleepy or
drowsy during the day or evening?| <*Answer_6481*>| 3. Did you take any naps or fall asleep briefly during the day or evening?| <*Answer_6482*>| 4. Did you feel you had been getting
an adequate amount of sleep?| <*Answer_6483*>| | | 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.| $~
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