Healthcare Fatigue Risks Assessment

Healthcare Fatigue Risks Assessment

Purpose: This assessment documents current symptoms, contributing factors, and risk indicators related to fatigue and drowsiness. Responses will be used for clinical evaluation, risk stratification, and development of a management plan. Provide accurate and complete information. If you are experiencing a medical emergency, seek immediate care.

Patient Information

Date of Assessment:    Date of Birth:    Gender:

Insurance / Coverage

Medical & Sleep History

Diagnosed Sleep Disorder:    Date of Diagnosis (if known):

Fatigue & Sleep Pattern Assessment

Typical Bedtime:    Typical Wake Time:    Frequent Naps:

Risk Factor Checklist

Shift work or rotating shifts
Frequent long work hours (>12 hours)
Drowsy driving or near-miss motor vehicle incidents
Use of sedating prescription or over-the-counter medications
Loud snoring, witnessed apneas, or gasping at night
Diagnosis of depression or anxiety contributing to sleep disturbance
Medical conditions associated with fatigue (e.g., hypothyroidism, anemia)

Screening Questions

Do you frequently feel excessive daytime sleepiness?   Yes   No

Have others observed that you stop breathing or choke/gasp while sleeping?   Yes   No

Do you fall asleep while driving or performing hazardous tasks?   Yes   No

Assessment, Recommendations & Authorization

Low   Moderate   High

I authorize the healthcare team to disclose fatigue assessment results to my employer/occupational health unit where necessary for safety or work accommodation purposes:
Yes   No

Privacy Acknowledgment & Consent

By signing below, I certify that the information provided in this Healthcare Fatigue Risks Assessment is true and complete to the best of my knowledge. I understand that this information will become part of my medical record and will be used for clinical care, safety determinations, and, if authorized, for communication with my employer or designated occupational health entity. I understand I may withdraw authorization to disclose information at any time in writing, except for disclosures already made in reliance on this authorization.

I acknowledge receipt of the Notice of Privacy Practices and understand my rights regarding protected health information.
Acknowledged   Declined

I understand that this assessment is not a definitive diagnostic test and that further evaluation, testing, or specialist referral may be required.

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