Worksheet 9.4: My Medical Sleep Questions and Referral Plan

Private Worksheet

This worksheet is for your private use.

You are not required to upload it, show it to a ministry leader, or disclose private medical information. You may share selected portions with a qualified healthcare professional if doing so would help you receive appropriate care.

This worksheet does not diagnose a sleep disorder or recommend treatment. Its purpose is to help you notice possible physical sleep blocks, prepare useful questions, protect safety, and choose one faithful next step.

Do not stop prescribed medication, change medication timing, begin or stop a supplement, discontinue CPAP or another prescribed device, or make another treatment change without qualified professional guidance.

Movement One: Pause and Pray

Become Present Before God

Sit or stand in a reasonably comfortable position.

Place your feet on the floor if that is comfortable and safe.

Allow your shoulders to lower.

You do not need to force your breathing, make yourself calm, or solve the entire problem right now.

Pray slowly:

Lord Jesus, I bring my whole organic life before you.
Help me listen to my body without fear, shame, or denial.
Give me wisdom to recognize what deserves attention.
Protect me from hasty conclusions and unsafe self-treatment.
Show me the next faithful step.
Amen.

My Present Nighttime Sentence

Complete one sentence:

Right now, I am feeling:

The main concern on my mind is:

One truth I want to remember is:

Possible truth:

I do not have to diagnose this myself. I can notice the pattern and seek wise help.

Movement Two: Notice and Name

Part A: What Have I Noticed?

Check only what applies.

Breathing and Snoring

☐ Loud, persistent snoring

☐ Breathing pauses observed by another person

☐ Choking, gasping, or snorting during sleep

☐ Awakening short of breath

☐ Morning headaches

☐ Dry mouth upon awakening

☐ Frequent nighttime urination

☐ Sleep that feels unrefreshing

☐ Another breathing concern:

Daytime Sleepiness and Alertness

☐ Strong daytime sleepiness

☐ Falling asleep unintentionally

☐ Difficulty concentrating

☐ Memory or attention problems

☐ Irritability that may be connected to exhaustion

☐ Difficulty remaining alert while driving

☐ Difficulty remaining alert during work or caregiving

☐ A near miss, accident, or safety concern

☐ Another alertness concern:

Legs, Movement, and Sensations

☐ An urge to move my legs while resting

☐ Uncomfortable leg sensations

☐ Symptoms that become worse in the evening or at night

☐ Temporary relief through movement or walking

☐ Repeated kicking or movement reported by another person

☐ Cramping, numbness, burning, or pain

☐ Another movement or sensation concern:

Pain and Physical Discomfort

☐ Pain makes it difficult to fall asleep

☐ Pain awakens me during the night

☐ I cannot find a comfortable or safe position

☐ Pain has recently become worse

☐ Pain is new or unexplained

☐ Reflux, coughing, itching, hot flashes, or another physical symptom affects sleep

☐ Another pain or physical concern:

Nighttime Behaviors and Sudden Changes

☐ Recurrent nightmares

☐ Fear of returning to sleep

☐ Acting out dreams through kicking, punching, shouting, or running movements

☐ Sleepwalking

☐ Falling out of bed

☐ Dangerous behavior while not fully awake

☐ A sudden unexplained change in sleep

☐ Sleeping much less while feeling unusually energetic

☐ Reduced need for sleep with agitation, impulsivity, or risky behavior

☐ Another nighttime behavior:

Part B: Describe the Pattern

What happens?

When did it begin?

How often does it happen?

☐ Less than once a week

☐ About once a week

☐ Several times a week

☐ Nearly every night

☐ I am not sure

Is the concern:

☐ Improving

☐ Staying about the same

☐ Becoming worse

☐ Changing in an unusual way

How does it affect the daytime?

☐ Fatigue

☐ Sleepiness

☐ Concentration

☐ Mood

☐ Memory

☐ Work

☐ Caregiving

☐ Relationships

☐ Driving

☐ Physical safety

☐ Another effect:

Part C: What Has Another Person Observed?

Complete this section only when another person has voluntarily shared an observation.

No one should be pressured to monitor, record, or disclose private information.

The person observed:

Their relationship to me:

What they noticed:

When they noticed it:

Part D: Name the Concern Without Diagnosing It

Avoid writing:

“I know I have sleep apnea.”

“I definitely have restless legs syndrome.”

“This medicine is causing everything.”

Instead, describe the observation:

“I have noticed:

This may deserve qualified evaluation because:

____________________________________________________________”

My Calm Medical Sentence

Complete this sentence:

I do not know the diagnosis, but I have noticed ___________________

and I would like qualified help understanding it.

The HELP Referral Check

H: Hear What the Body May Be Communicating

What repeated signal deserves attention?

What have I been tempted to minimize?

What have I been tempted to fear or exaggerate?

A balanced statement:

Example:

This symptom may have several possible causes. I will take it seriously without assuming the final diagnosis.

E: Examine the Pattern and Urgency

Which description best fits my current concern?

☐ Mild, occasional, and not affecting daily life

☐ Recurring and worth discussing at a routine appointment

☐ Persistent and affecting daily functioning

☐ Worsening and requiring prompt evaluation

☐ Creating a driving, work, fall, breathing, or other safety risk

☐ Possibly urgent or emergent

Immediate Safety Review

Check any concern that is present now:

☐ Severe breathing difficulty

☐ Chest pain

☐ Seizure

☐ Dangerous confusion

☐ Loss of consciousness

☐ Suicidal intent or immediate self-harm risk

☐ Violence or danger to another person

☐ Suspected overdose or severe medication reaction

☐ Dangerous substance impairment

☐ Serious injury during sleep

☐ Another immediate danger:

When an immediate danger is present, follow local emergency procedures. Do not wait for a routine appointment or attempt to solve the situation through a sleep practice alone.

Driving and Safety-Sensitive Activity

Have I recently struggled to remain awake while driving?

☐ Yes

☐ No

☐ I am uncertain

Have I drifted from my lane, missed exits, hit a rumble strip, or forgotten part of a drive?

☐ Yes

☐ No

Have I struggled to stay awake while using tools, machinery, caring for another person, or performing safety-sensitive work?

☐ Yes

☐ No

My immediate safety decision is:

Example:

I will not drive when I am struggling to remain awake. I will arrange another form of transportation.

L: List Observations, Medicines, and Questions

My Usual Sleep Pattern

Usual bedtime:

Usual wake time:

Approximate time needed to fall asleep:

Number of awakenings:

Typical length of awakenings:

Naps:

Shift work, caregiving, parenting, travel, or schedule factors:

Current Health Conditions

List only what you are comfortable recording privately.

Recent Changes

Check any that apply:

☐ New illness

☐ Recent surgery or injury

☐ New pain

☐ Pregnancy or postpartum change

☐ Menopause-related change

☐ Significant weight change

☐ New stress or grief

☐ New medication

☐ Medication dose change

☐ Increased alcohol, caffeine, nicotine, or substance use

☐ Reduction or withdrawal from a substance

☐ Change in work schedule

☐ Another change:

Medication and Substance List

Include prescriptions, over-the-counter products, vitamins, herbal products, supplements, caffeine, alcohol, nicotine, cannabis-related products where applicable, and other substances.

Prescribed Devices or Treatments

Do I use a prescribed device or treatment such as CPAP?

☐ Yes

☐ No

If yes, what is it?

Am I having difficulty using it?

☐ Yes

☐ No

What difficulty am I experiencing?

Do not stop a prescribed device without professional guidance.

My Most Important Medical Questions

Choose or write the questions that matter most.

☐ Could a breathing disorder be disrupting my sleep?

☐ Do my symptoms suggest that a sleep evaluation is needed?

☐ Would a home sleep apnea test be appropriate, or is another test needed?

☐ Could one of my medicines or supplements affect my sleep?

☐ Could a medicine be contributing to daytime sleepiness?

☐ Could alcohol, caffeine, nicotine, or another substance be contributing?

☐ Could pain or another health condition be disturbing my sleep?

☐ Do my leg sensations need evaluation?

☐ Could pregnancy, postpartum changes, menopause, or aging be relevant?

☐ Could my nightmares or nighttime behaviors require specialized help?

☐ Is my daytime sleepiness creating a driving or work risk?

☐ Would a qualified CBT-I provider be appropriate?

☐ What symptoms should cause me to seek urgent help?

☐ What should I continue doing while waiting for evaluation?

☐ Another question:

My three highest-priority questions are:

P: Pursue Qualified Help

Which professional may be the best starting point?

☐ Primary-care clinician

☐ Sleep specialist

☐ Pharmacist

☐ Qualified CBT-I provider

☐ Licensed mental-health professional

☐ Pain professional

☐ Obstetric or maternal-health professional

☐ Menopause-care professional

☐ Neurologist

☐ Respiratory or pulmonary professional

☐ Community clinic

☐ Telehealth service

☐ Emergency service

☐ I am not sure where to begin

My most realistic starting place is:

Contact information:

The person who may help me make or attend the appointment is:

Barriers to Seeking Help

What may make it difficult to seek care?

☐ Cost

☐ Insurance

☐ Transportation

☐ Distance

☐ Work schedule

☐ Childcare

☐ Caregiving

☐ Language

☐ Disability access

☐ Fear of diagnosis

☐ Fear of treatment

☐ Embarrassment

☐ Previous experience of not being heard

☐ I do not know where to go

☐ Another barrier:

One person or resource that may help with this barrier:

A low-cost or accessible first step:

Possible examples include a community clinic, primary-care office, pharmacist, telehealth service, government health program, regional hospital, or maternal-health clinic.

Movement Three: Welcome Scripture and the Holy Spirit

Choose a Scripture

Check one or write another passage.

☐ James 1:5 — Ask God for wisdom.

☐ Proverbs 15:22 — Plans are established through wise counsel.

☐ Psalm 121:3–5 — The Lord watches over his people.

☐ Psalm 139:13–16 — God knows our embodied lives.

☐ Luke 5:31 — Those who are sick need a physician.

☐ 1 Corinthians 6:19–20 — Honor God in embodied life.

☐ Romans 8:1 — There is no condemnation in Christ.

☐ Another Scripture:

Write the words or truth that stand out:

My Scriptural Self-Conversation

Complete these sentences:

My sleep difficulty is not proof that:

Seeking medical help does not mean:

Because I belong to Jesus Christ, I can:

The truth I want to carry into tonight is:

A Prayer for Wisdom and Referral

Holy Spirit, help me recognize what is true without becoming ruled by fear.

Show me what requires calm observation, what deserves a routine conversation, what needs prompt evaluation, and what calls for urgent action.

Give me courage to describe my symptoms honestly. Help me receive the wisdom of qualified professionals without making a diagnosis my identity.

Protect me from unsafe self-treatment, denial, panic, and shame.

Lead me toward the help I need and give me peace for what cannot be answered tonight.

Amen.

Movement Four: One Faithful Step

Choose One Realistic Action

I will:

☐ Make a routine medical appointment

☐ Request a prompt evaluation

☐ Contact a pharmacist for a medication review

☐ Ask about a sleep-specialist referral

☐ Prepare my medication and substance list

☐ Keep a simple sleep record for a clinician

☐ Ask a trusted person what they have observed

☐ Arrange transportation because driving feels unsafe

☐ Avoid driving when dangerously sleepy

☐ Follow local emergency procedures for an urgent concern

☐ Continue prescribed treatment while seeking guidance

☐ Ask about an accessible or lower-cost healthcare option

☐ Invite a trusted person to attend an appointment

☐ Speak with a licensed mental-health professional

☐ Another faithful step:

My Action Plan

My chosen action:

I will take this step on or by:

The person or service I will contact:

What I will say:

I have noticed _____________________________________________
It has been happening ______________________________________
It is affecting _____________________________________________
I would like help understanding ______________________________

My Safety Plan Until I Receive Help

I will avoid:

I will continue:

I will seek urgent help if:

The person who should know about my immediate safety plan is:

My Nighttime Release Sentence

Choose or write one:

☐ I have noticed the concern, and I am taking a faithful next step.

☐ I do not have to determine the diagnosis tonight.

☐ I can seek wise care without shame.

☐ I will protect safety and release what cannot be settled tonight.

☐ God is present while I wait for answers.

☐ My own sentence:

My Medical-Conversation Preparation Sheet

You may copy or share this section with a qualified healthcare professional.

Main Concern

When It Began

How Often It Happens

What Happens During the Night

What Happens During the Day

What Another Person Has Observed

Important Health or Medication Changes

Driving or Safety Concerns

My Three Main Questions

Final Reflection

What did I learn by completing this worksheet?

What concern do I now understand more clearly?

What am I releasing to God tonight?

What is my next faithful step?

Closing Prayer

Lord Jesus, thank you for meeting me as an organic human with spiritual and physical life before you.

I have named what I can see. I have acknowledged what I do not know. Give me courage to protect safety, ask good questions, and receive qualified care.

Help me prepare wisely without trying to control every outcome. Guard me from shame and remind me that seeking help is not failure.

Bless the professionals, family members, friends, pastors, chaplains, and others who may support me. Give them wisdom, compassion, and appropriate boundaries.

I place my body, my questions, my appointments, my fears, and this coming night in your care.

Amen.

Private Portfolio Asset

Place this completed worksheet, or a brief summary of it, in your private Sleep in Peace Portfolio under:

Medical Sleep Questions and Referral Plan

You are not required to upload it or show it to anyone. Completion may be privately self-attested.