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Case Study Report Form

Please fill out the following form if you have a Case Study Report.

Please provide submitter information (therapist or clinic director) so that we can contact you if we need clarification.
*Name:
*Contact Phone:
*Contact Email:
Please Indicate how you want this information credited:

Patient Information
*Sex:
*Age:
Race:
Education:
Marital Status:

Presenting Problem:
Age of onset:
Duration of illness (since age of onset):
Duration of index episode (current bout):

Retrospective Assessment (From Intake Interview)
*Time to Bed:
*Time out of bed:
*SL:
*WASO:
*NWAK:
*TST:
* Medical Issues (DX and Duration of illness, Acute issues): e.g., Hypercholesterolemia; 6 years; Lipitor 20mg qam; po
* Psych Issues (DX and Duration of illness, Acute issues): e.g., Depression; 10 years duration, current status: remission; Mirtazapine: 15 mg; qd; po
Complicating Factors (Feel free to detail this. Really explain what makes the case interesting, a good example of x,y, or z):
Sleep Restriction (If yes, Specify how accomplished): e.g., TIB restricted to average TST as assessed by two weeks of sleep diaries Titration by the > 90% (up), 85-90% (stick), < 85% (down)
Stimulus Control (If yes, Specify how accomplished):
Sleep Hygiene (If yes, Specify how accomplished):
Cognitive therapy (If Yes, Specify type, method and # sessions):
Other

*Tx Outcome by Session - A PDF EXAMPLE OF A COMPLETE CASE REPORT
	B	1	2	3	4	5
*SL
*NWAK
*WASO
*TST
*TIB
*SE%

	6	7	8	9	10
*SL
*NWAK
*WASO
*TST
*TIB
*SE%

Please contact Michael Perlis, PhD at mperlis@exchange.upenn.edu if you have any questions or concerns.

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