Page 1 of 3 APPROVED BY MUIC September 3, 2015

ADDENDUM I - NON SEDATIVE-HYPNOTIC TREATMENT OF INSOMNIA TOOLKIT SCOPE: This toolkit is intended to offer non sedative-hypnotic treatment options for providers, clients and the interested general public for the treatment of insomnia. It is a supplement to the BHS safer prescribing of sedative-hypnotic guidelines. GENERAL CONSIDERATIONS: Insomnia is often a symptom of a comorbid condition. Left untreated over time, patients may develop numerous psychological and behavioral issues that exacerbate insomnia- worrying about inability to sleep or daytime consequences of poor sleep, having distorted beliefs about the origin or meaning of insomnia, making schedule changes to accommodate the insomnia, and spending excessive time in bed. Treatment of insomnia should begin by treating comorbidities (such as major depression, pain, and movement disorders) or by eliminating activating medications. Psychologic and behavioral treatment should restructure maladaptive cognitions and establish healthy sleep habits/environments. Short term pharmacological treatment may be used to supplement these therapies. (JCSM Guidelines for Insomnia) SPECIAL CONSIDERATIONS FOR OLDER ADULTS: The use of sedative-hypnotics in older adults should be avoided due to increased risk of adverse events including falls and hip fractures that can lead to hospitalization and death, increased risk of delirium, cognitive impairment and motor vehicle accidents. A recent meta-analysis compared the evidence of various interventions for tapering off benzodiazepines in older adults. This study found that supervised taper augmented with psychotherapy, such as CBT, resulted in higher odds of not using benzodiazepines post-intervention. Other interventions studies included taper plus a provider prescribing intervention (education, medication regimen reviews, prescribing feedback) and taper plus pharmacotherapy. (Gould et al, 2014) SPECIAL CONSIDERATIONS FOR CONCOMITANT OPIOID TREATMENT: Studies show that 50-90% of patients with chronic pain also suffer from a sleep disturbance. Individuals in recovery from substance use disorders also tend to display sleep disturbances. The combination of opioids and sedative-hypnotics can create synergistic sedation with a risk of dangerous respiratory depression (Smith 2004). Recent guidelines from the American Society of Interventional Pain Physicians as well as BHS Safer Sedative-Hypnotic Prescribing Guidelines suggest that the use of sedative-hypnotic medications are relatively to absolutely contraindicated in individuals on chronic opioid treatment because of the safety risks. Because of the heightened risks of sedative-hypnotic medications and the high rate of sleep disturbances, alternative treatments for insomnia are needed. PATIENT RESOURCES: SLEEP DIARY: This can be used by patients to track their sleep patterns. Attachment 1: https://www.sfdph.org/dph/files/CBHSdocs/SleepDiary.pdf SLEEP HYGIENE HANDOUT FOR PATIENTS: The American Academy of Sleep Medicine recommends that patients practice good sleep hygiene techniques in combination with other treatments for insomnia. This is an easy-to-read handout that reviews healthy sleep habits that can be given directly to patients. Attachment 2: English: https://www.sfdph.org/dph/files/CBHSdocs/SleepHabits-ENGLISH.pdf Spanish: https://www.sfdph.org/dph/files/CBHSdocs/SleepHabits-SPANISH.pdf Chinese: https://www.sfdph.org/dph/files/CBHSdocs/SleepHabits-CHINESE.pdf Vietnamese: https://www.sfdph.org/dph/files/CBHSdocs/SleepHabits-VIETNAMESE.pdf Tagalog: https://www.sfdph.org/dph/files/CBHSdocs/SleepHabits-TAGALOG.pdf Russian: https://www.sfdph.org/dph/files/CBHSdocs/SleepHabits-RUSSIAN.pdf

Page 2 of 3 APPROVED BY MUIC September 3, 2015

SEDATIVE-HYPNOTIC OLDER ADULT PATIENT EDUCATION: The EMPOWER trial mailed 148 chronic benzodiazepine consumers aged 65-95 an 8-page education brochure on the risks of taking sedative-hypnotics along with a picture of a 20-week tapering protocol. After 6 months, 27% of individuals who received this intervention had discontinued their benzodiazepines and an additional 11% had reduced their dose (Tannenbaum et al, 2014). This handout can be given to clients as an educational tool to support clients during a taper of a sedative-hypnotic. Attachment 3: https://www.sfdph.org/dph/files/CBHSdocs/EmpowerPatientHandout.pdf PROVIDER RESOURCES: CBT: CBT geared specifically for insomnia (CBT-I) has been found to improve sleep quality, reduce use of sedative-hypnotic medications and improve quality of life in a cost-effective manner. (Morgan et al, 2004). These handouts are outlines of CBT-I sessions and can be used by providers as a guide for non-pharmacologic management of insomnia. Attachment 4: https://www.sfdph.org/dph/files/CBHSdocs/CBTforInsomniaHandout.pdf SLEEP CLINIC REFERRAL: Sleep studies can be beneficial for ruling out medical causes of insomnia such as sleep apnea. Clients with Medi-Cal, Medicare or Medi-Medi may be referred to a sleep specialist, Dr. David Claman, at UCSF. For more information on Dr. Claman, see http://www.ucsfhealth.org/david.claman. For general information on referral to specialty clinics at UCSF, please visit http://www.ucsfhealth.org/health_professionals/make_a_referral/. The referral form can be accessed at http://www.ucsfhealth.org/pdf/referral.pdf, or here: https://www.sfdph.org/dph/files/CBHSdocs/UCSF-SleepClinicReferral.pdf NON SEDATIVE-HYPNOTIC OR NON ANTICHOLINERGIC MEDICATIONS FOR INSOMNIA: Name Dosage

range Mechanism Comments

Doxepin 3-10mg Tricyclic antidepressant Doses >10mg will have anticholinergic effects.

Gabapentin 100-1200mg Structurally related to GABA, may modulate the release of excitatory neurotransmitters

May also be helpful for neuropathic pain.

Melatonin 3-5mg Natural hormone, regulates circadian rhythms

Works best if combined with exposure to sunlight during the day.

Mirtazapine 7.5-45mg Central presynaptic alpha-2 antagonist

Lower doses are more sedating. May increase appetite, triglycerides. May cause weight gain.

Ramelteon 8mg Melatonin receptor agonist Mild therapeutic effect, not covered by many insurance companies.

Trazodone 12.5-300mg Potentiates serotonergic activity in the CNS

Start at low doses, may have “hangover” feeling in the morning.

Page 3 of 3 APPROVED BY MUIC September 3, 2015

BACKGROUND: In 2008, 5.2% of adults aged 18-80 in the United States filled a prescription for a benzodiazepine. The percentage of adults who use benzodiazepines increased with age from 2.6% (18-35 years) to 8.7% (65-80 years). Of those older adults (65-80 years) who use benzodiazepines, 31.4% are using them long term. A majority of benzodiazepine prescriptions were prescribed by non-psychiatrists. The rates of benzodiazepine prescribing by psychiatrists declined with increasing patient age. Research suggests that a significant portion of sedative-hypnotics are prescribed for insomnia (Olfson 2015). BHS Safer Sedative-Hypnotic Prescribing Guidelines recommend careful assessment and documentation for all clients in whom a sedative-hypnotic prescription is considered. Non-pharmacologic techniques and non-addictive medications are recommended to be used prior to sedative-hypnotic medications. Long term use of sedative-hypnotics should be avoided, especially in certain high risk populations such as older adults and clients on opioid medications. Offering psychosocial support and education during sedative-hypnotic taper is recommended. However the guideline does not include specifics regarding these parameters (BHS Safer Sedative-Hypnotic Prescribing Guidelines). REFERENCES AND FURTHER READING:

1. Billoti S, Moride Y, Ducruet T, et al. Benzodiazepine use and risk of Alzheimer’s disease: case-control study. BMJ. 2014;349:g5205 doi: 10.1136/bmj.g5205.

2. Gould RL, Coulson MC, Patel N, et al. Interventions for reducing benzodiazepine use in older people: meta-analysis of randomized controlled trials. Br J Psychiatry. 2014;204: 98-107. doi: 1192/bjp.bp.113.126003.

3. Olfson M, King M, Schoenbaum M. Benzodiazepine Use in the United States. JAMA Psychiatry. 2015;72(2):136-142. doi:10.1001/jamapsychiatry.2014.1763.

4. Tannenbaum C, Martin P, Tamblyn R, et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014;174:890–8.

5. Morgan K, Dixon S, Mathers N, Thompson J, Tomeny M. Psychological treatment for insomnia in the regulation of long-term hypnotic drug use. Health Technol Assess 2004;8(8).

6. Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine. 2008;4(5):487–504.

7. Smith MT, Haythornthwaite JA. How do sleep disturbance and chronic pain interrelate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Medicine Reviews. 2004;8(2):119.132.

8. Manchikanti L, et al. American Society of Interventional Pain Physicians (A SIPP) Guidelines for Responsible Opioid Prescribing in Chronic Non-Cancer Pain: Part 2- Guidance Guidelines. Pain Physician. 2012;15(3 Suppl):S67-S116.

Managing Insomnia: an example sequence of CBT-based sessions for sleep treatment

Session 1: Introduction and sleep assessment -Assess sleep problem (option: have client complete 20-item sleep questionnaire). -Assess for comorbid mental health issues (anxiety, depression) or substance use (including caffeine). -Provide education on normal sleep. -Homework: Client takes home daily sleep diary to complete for 7 days Session 2: Basic sleep hygiene -Review sleep diary -Review sleep hygiene handout with client & help client identify items from the sleep hygiene that they can apply before the next visit. -Give client the Sleep Education & Sleep Hygiene handouts. Session 3: Stimulus control and sleep restriction -Review current sleep-wake patterns and set an agreed bedtime and wake-up time, which the client will try to stick to before the next visit. -Review how the client is currently using their bed, and how they can limit bed to just sleep. -Educate client on sleep restriction and make plan for client to get up and leave bed any time they cannot sleep for 20 minutes, to sit in a chair (or in another room if possible) until they feel tired again. -Give client the Stimulus Control and Sleep Restriction handout. Session 4: Progressive relaxation -Educate on normal physical & mental changes during sleep. -Help client develop and practice a relaxation technique (which may include elements of meditation, mindfulness, progressive muscle relaxation, deep breathing, and/or grounding, and should include mentally envisioning a pleasant thing or place) and schedule a time for the client to practice this on their own for 25 minutes every day until the next session. -Give client the Progressive Relaxation handout. Session 5: Cognitive techniques -Discuss how negative or worrying thoughts can get in the way of sleep, and how sleep will occur naturally without having to try if obstacles such as these thoughts are removed -Help client schedule a time during the daytime to anticipate worrisome thoughts that they expect may come that night, so they can attempt to address them in the day (journaling about them may help) -Help client identify negative automatic thoughts about sleep, & then challenge those thoughts by identifying more realistic alternatives of the same thoughts. -Review techniques for calming the mind at bedtime: (1) using visual imagery, such as picturing a pleasant scene; (2) “blocking” bothersome or unimportant thoughts at night with a strategy such as the patient repeating the word “THE” every 2 seconds in their head; (3) catching any automatic negative thoughts & remembering the more realistic alternative. -Give the client the Cognitive Techniques handout

Managing Insomnia- Sleep Education & Sleep Hygiene

Whatever the cause of your present problem there are still things you can do that will help you get the most out of your sleep now:

• Don’t expect too much from your sleep. As you get older it is quite normal for sleep to become shorter, lighter, and more broken. You may also find that your normal sleep routines are more easily disturbed. Rather than changing your sleep, you may need to adjust your expectations and your habits. Do you really need as much sleep as your think?

• Avoid those things which can prevent or disrupt sleep (even if these things have never been a problem in the past). Learn to take more care of your sleep. For example, try drinking less tea or coffee (especially close to bedtime). If you have to get up in the night to go to the toilet, perhaps it is best to avoid late night drinking altogether.

• Is your bed comfortable and warm enough, and is your bedroom quiet and dark enough?

• It is extremely important to keep regular habits. In particular, avoid excessive daytime napping, or long lie-ins in the morning.

• Try to keep at least fairly active during the day, but allow time to ‘wind down’ in the evening.

• If you have a medical complaint that seems to interfere with your sleep (for example, pain, breathlessness, snoring, or frequent urination at night), see your primary care doctor and explain the problem.

Managing Insomnia- Stimulus Control and Sleep Restriction

Beds and bedrooms are very important ‘signals’ for sleep, and actually make a lot of people feel quite sleepy. For those with insomnia, however, these important signals may be lost. With practice, these signals or ‘cues’ can be strengthened so that your sleep gradually improves. The main aim of this treatment approach is to reduce the amount of time you spend awake in bed each night. Listed below are some rules to follow.

• Establish a set bedtime for yourself. Try to go to bed at this same time each night and settled down to sleep as soon as possible.

• If you have not gone to sleep after about 20 minutes, get up and leave the bedroom (if possible) until you feel tired again. If you live in one room and cannot leave, at least leave the bed (for example, sit in a chair instead) until you feel tired.

• It is important that you do not use your bed for anything except sleep. Avoid activities like reading, smoking, listening to the radio, using the computer, or watching TV in bed. If you can’t sleep, get up.

• Establish a set wake-up time for yourself, and get up at the set time even if you feel tired or in need of more sleep.

• Try to keep active during the day and avoid napping.

• Go to bed at the set time. Before putting these rules into practice, you may find it helpful if you first prepare a room or area in your room where you can sit during sleepless periods, and if there are other people you live with, tell them about your sleep treatment.

Managing Insomnia- Progressive Relaxation

Physical and mental relaxation are a normal and natural part of good sleep. As we drift into sleep we experience several changes, both in our physical arousal and in our thinking pattern. With sleep –

• Breathing slows down

• Heart rate slows down

• Muscles relax

• Patterns of thinking change from problem solving which is usually in words, to thoughts in pictures and images

These changes are a normal and natural part of good sleep, just as it is normal for our heart rate and breathing to speed up when we exercise. When we prepare for sleep we begin the process of putting our minds and bodies to bed. You can give the natural process a helping hand, by learning a good, deep relaxation. This will help you to reduce your physical arousal, by slowing down your heart rate and breathing and by reducing muscle tension. By focusing on the relaxation you will also stop your mind from racing, you will keep thoughts which might otherwise get in the way of sleep and you will help the natural shift in your thinking from words to pictures. This will help you to achieve a relaxed state and allow you to drift into sleep. PRACTICE

• Set aside 25 minutes each day, at a convenient time when you will not be disturbed, to practice your relaxation/meditation. If you need tips on how to do this, ask your provider. The more you practice the deeper your relaxation will become and the more it will help you to achieve a good night’s sleep.

• Once in bed, settle down prepared to sleep and again go through the relaxation. At the end try to hold in your mind the details of a pleasant image. Hold this as vividly as you can, see the colors and movements and hear the sounds, etc.

REMEMBER

• Beware of excuses which prevent you from practicing every day

• Don’t fall asleep during your daytime relaxation/meditation practice

• Don’t expect changes in your sleep immediately, as it takes time. Just focus on enjoying the relaxation.

Managing Insomnia- Cognitive Techniques

Let’s consider how we can put our minds to bed and stop thoughts from getting in the way of good sleep. Thoughts which get in the way of sleep might be worrying thoughts, which are often about the day that has gone, or the day to come. Put the day to rest We have to put the day to rest. It is helpful to guess what bedtime thoughts may be ahead of time, by rescheduling them to earlier in the day. Set aside time to pay attention to these thoughts in the daytime—a good way is to write them down, perhaps as a journal of the day. We can write details about the day past or to come, and try to tie up loose ends. Change troublesome or negative thoughts into trouble-free realistic thoughts Negative thoughts can be challenged by more realistic versions of the same thoughts, such as: Negative thought Realistic thought

I am never going to sleep tonight. I always fall asleep eventually.

I won’t cope tomorrow. I will be tired but I will get through it.

I will get sick if I don’t sleep. Insomnia does not cause illness.

Everyone else is asleep. I am not alone—1 in 5 adults have sleep trouble.

Change negative thoughts to realistic thoughts by challenging your beliefs

Catch the thoughts you want to block or challenge. These thoughts are often involuntary, habitual, negative, exaggerated or even defeatist. Ask yourself: 1. Is this thought or fact? 3. What is the evidence to support this thought? 2. Am I jumping to conclusions? 4. What is a more realistic alternative thought? A calm mind at bedtime Once in bed settle down quickly and go through your relaxation technique. Use imagery by holding a pleasant scene in your mind. Attempt to block repetitive, unimportant thoughts—one technique is to repeat the word “THE” every two seconds in your head. Remind yourself that you have already put your thoughts to bed. If any disruptive thoughts enter your mind, remind yourself of the realistic alternative you identified during the day. Then use you imagery or block technique to distract yourself and drift into sleep.

No need to try to sleep There is no need to try to sleep! Sleep is natural and will occur if we remove the things that keep us awake. Don’t expect too much too quickly, it takes time

Sleep Diary One of the best ways you can tell if you are getting enough good quality sleep, and whether you

have signs of a sleep disorder is by keeping a sleep diary. Use this sample diary to get started.

Complete

in the

Morning

Name

Day of the week Mon Tues Wed Thurs Fri Sat Sun

Today’s date

Time I went to bed last night:

Time I woke up this morning:

Number of hours slept last night:

Number of awakenings:

Total time awake last night:

Time to fall asleep last night:

How awake did I feel when I got

up this morning?

1—Wide awake

2—Awake but a little tired

3-- Sleepy

Complete

in the

Evening

Name

Day of the week Mon Tues Wed Thurs Fri Sat Sun

Today’s date

Number of caffeinated drinks

(coffee, tea, cola) and time when I

had them today:

Number of alcoholic drinks (beer,

wine, liquor) and time when I had

them today:

Naptimes and length of naps

today:

Exercise times and length of

exercise today:

How sleepy did I feel during the

day today?

1—Very sleepy

2—Somewhat tired

3—Fairly alert

4—Wide awake

Do’s

o DO: Establish a regular bedtime and rise

time

o DO: Only use bed for sleep (if possible)

o DO: Exercise in the morning or early

afternoon

o DO: Take a hot bath a couple of hours

before bedtime

o DO: Establish a comfortable sleep

environment (e.g., bed, and bedding)

o DO: Sleep in a dark, quiet area that is

temperature controlled (if possible)

o DO: Establish a relaxing pre-sleep routine

that you use every night before sleep,

such as washing your face, getting into

pajamas, reading or listening to soft

music before turning the lights out

Don’ts

• DON’T: Take daytime naps

• DON’T: Watch TV in bed

• DON’T: Use stimulants such as caffeine

and nicotine

• DON’T: Drink alcohol before bedtime

• DON’T: Go to bed too hungry or too full

• DON’T: Eat spicy or acidic foods (e.g.,

orange juice) before bed

• DON’T: Try too hard to fall asleep

• DON’T: “Watch the clock”

• DON’T: Take prescription and over-the-

counter medications that might be

stimulating (check with your doctor)

Los Sí y los No de los hábitos del sueño Sí

o SÍ: Establezca un horario regular para dormirse y levantarse

o SÍ: Use solamente la cama para dormir (si es posible)

o SÍ: Haga ejercicio en la mañana o temprano en la tarde

o SÍ: Tome un baño caliente un par de horas antes de acostarse

o SÍ: Establezca un ambiente cómodo para dormir (por ejemplo, cama y ropa de cama)

o SÍ: Duerma en una zona oscura y tranquila donde se controle la temperatura (si es posible)

o SÍ: Establezca una rutina relajante que utilice todas las noches antes de dormir, como lavarse la cara, ponerse pijama, leer o escuchar música suave antes de apagar las luces

No

• NO: Tome siestas durante el día

• NO: Vea la televisión en la cama

• NO: Utilice estimulantes como la cafeína y la nicotina

• NO: Beba alcohol antes de acostarse

• NO: Se acueste con hambre o demasiado lleno

• NO: Coma alimentos picantes o ácidos (por ejemplo, jugo de naranja) antes de acostarse

• NO: Haga demasiado esfuerzo para dormirse

• NO: "Mire el reloj"

• NO: Tome medicamentos de receta ni de venta libre que puedan ser estimulantes (consulte a su médico)

Привычки сна "Можно и нельзя"

Можно

o МОЖНО: Установите привычку ложиться

и вставать в одно и то же время

o МОЖНО: Используйте кровать только для

сна (если возможно)

o МОЖНО: Занимайтесь спортом по утрам

или в середине дня

o МОЖНО: Принимайте ванну за пару

часов до сна

o МОЖНО: Создайте комфортные условия

для сна (напр., кровать и постельное

белье)

o МОЖНО: Спите в темном и тихом

помещении с температурным контролем

(если возможно)

o МОЖНО: Создайте расслабляющую

рутину подготовки ко сну, которой вы

будете следовать каждый вечер, напр.,

умывание лица, переодевание в пижаму,

чтение или прослушивание тихой музыки

перед тем, как выключить свет.

Нельзя

• НЕЛЬЗЯ: Спать днем

• НЕЛЬЗЯ: Смотреть телевизор в кровати

• НЕЛЬЗЯ: Пользоваться стимуляторами,

напр. кофе и никотин

• НЕЛЬЗЯ: Пить спиртное перед сном

• НЕЛЬЗЯ: Ложиться в кровать слишком

голодным или переевшим

• НЕЛЬЗЯ: Есть острую или кислую пищу

(напр., апельсиновый сок) перед сном

• НЕЛЬЗЯ: Очень стараться уснуть

• НЕЛЬЗЯ: “Следить за временем”

• НЕЛЬЗЯ: Принимать прописанные врачом

или продающиеся без рецепта лекарства

с возможным возбуждающим эффектом

(проконсультируйтесь с вашим врачом)

要要要要

o 要: 定時睡覺和起床

o 要: (如果可能) 睡床只作睡覺之用

o 要: 在早上或下午做些運動

o 要: 在睡前兩個小時以熱水淋浴

o 要: 有舒適的睡眠環境

(如，睡床和床上用品)

o 要: (如果可能) 在燈暗及安靜的恆溫環

境下睡覺

o 要: 養成每晚睡前放鬆的習慣，如洗臉、

穿上舒服的睡衣、閱讀或關燈前聆聽輕

音樂

不不不不要要要要

• 不要: 白天小睡

• 不要: 在床上看電視

• 不要: 服用帶刺激性的物品，如咖啡因

和尼古丁

• 不要: 睡前飲酒

• 不要: 睡前太餓或太飽

• 不要: 睡前吃辛辣或酸性的食品 (如

橙汁)

• 不要: 強迫自己入睡

• 不要: “看時鐘”

• 不要: 服用可能有刺激性的處方藥和非

處方藥 (請諮詢你的醫生)

Những cái Nên làm

o Nên: Thiết lập giờ giấc đều đặn cho việc

đi ngủ và thức dậy

o Nên: Chỉ sử dụng giường cho việc ngủ mà

thôi (nếu có thể)

o Nên: Tập thể dục vào buổi sáng hoặc đầu

giờ trưa

o Nên: Tắm nước nóng một vài tiếng trước

giờ đi ngủ

o Nên: Thiết lập một không gian ngủ thoải

mái (ví dụ: giường, chăn nệm)

o Nên: Ngủ ở một nơi tối, yên tĩnh, nhiệt

độ có thể kiểm soát (nếu có thể)

o Nên: Thiết lập một thói quen thư giãn

trước khi đi ngủ như rửa mặt, mặc quần

áo ngủ. đọc sách hoặc nghe nhạc nhẹ

trước khi tắt đèn.

Những cái Không nên làm

• Không nên: Ngủ ban ngày

• Không nên: Nằm xem TV trên giường

• Không nên: Dùng những chất kích thích

như caffeine và nicotine (Coca cola,

thuốc lá)

• Không nên: Uống rượu trước khi đi ngủ

• Không nên: Đi ngủ khi bụng quá đói hoặc

quá no

• Không nên: Ăn thức ăn cay hoặc nhiều

chất axít (ví dụ: nước cam) trước khi đi

ngủ

• Không nên: Cố gắng quá mức để ngủ

• Không nên: “Nhìn đồng hồ”

• Không nên: Uống thuốc theo toa hoặc

bán trên quầy có những chất kích thích

(hỏi bác sĩ của bạn)

Mga Dapat Gawin

o GAWIN: Magkaroon ng regular na oras ng pagtulog at

paggising

o GAWIN: Gumamit lamang ng kama sa pagtulog (kung

maaari)

o GAWIN: Mag-ehersisyo sa umaga o bandang maaga

sa hapon

o GAWIN: Maligo ng ilang oras gamit ang mainit na

tubig bago matulog

o GAWIN: Magkaroon ng maginhawang kapaligiran sa

pagtulog (hal., kama, at unan/kumot)

o GAWIN: Matulog sa madilim, tahimik na lugar na

kontrolado ang temperatura (kung maaari)

o GAWIN: Magkaroon ng isang nagpapaginhawang

gawain na inyong gagawin sa bawat gabi bago

matulog, gaya ng paghihilamos ng inyong mukha,

pagsusuot ng padyama, pagbabasa o pakikinig ng

malamlam na musika bago patayin ang ilaw

Mga Hindi Dapat Gawin

• HUWAG: Umidlip sa araw

• HUWAG: Manood ng TV sa kama

• HUWAG: Gumamit ng mga pampasigla gaya ng kapin

at nikotina

• HUWAG: Uminom ng alak bago matulog

• HUWAG: Matulog nang sobrang gutom o sobrang

busog

• HUWAG: Kumain ng mga pagkaing maanghang o

maasim (hal., orange juice) bago matulog

• HUWAG: Sikaping mabuti na makatulog

• HUWAG: “Bantayan ang relo”

• HUWAG: Gumamit ng mga nireseta at nabibili sa

kaunter na mga gamot na maaaring magpasigla

(tanungin ang inyong doktor)

R E F E R R A L F O R M

Thank you for choosing to refer your patient to us. To start the referral process, please fax thisform to the UCSF service to which you are referring your patient.

� Fax numbers can be found online at www.ucsfhealth.org/prd/� Include brief pertinent medical records, including test results that support the consultation

If you require additional assistance, please call (800) 444-2559 and ask for either the UCSF practiceor the Physician Liaison Service.

Date:

No. of pages:

To UCSF practice:

Fax:

From:

Title:

Phone:

Fax:

PAT I E N T I N F O R M AT I O N

Name of patient:

DOB: Interpreter needed: � Yes � No Language:

Home phone: � Work or � cell phone:

If child, name of parent:

Address:

City: Zip:

Insurance: Include patient’s insurance card (both sides) and HMO authorization if required

C O N S U LTAT I O N R E Q U E S T I N F O R M AT I O N

Diagnosis/ICD-9:

Name of UCSF MD (if known): Specialty:

Reason for consultation:

By providing the information requested and signing below, you agree that we may initiate treatmentfollowing consultation or perform medically necessary diagnostics, in association with this consultation.We look forward to collaborating with you on your patient’s treatment plan.

R E F E R R I N G P H Y S I C I A N I N F O R M AT I O N

Referring MD: Specialty:

Phone: Fax:

PCP name: Phone:

Signature:

NOTICE OF CONFIDENTIALITY: This is a confidential fax and is intended solely for the person indicated above. If you are not the intended person, you arehereby notified of the confidential nature of this fax and that you are not entitled to read, copy or otherwise disseminate any of the information contained herein.