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Daniel Reyes

Valiant Sleigh

DOB 09/08/1982 44 yrs Phone —

Appointment Sun 8 Nov 2026, 3:00 pm Mental health · Psych

All intakes

Today 3:00 pm Summary

Consult notes

AI-drafted from the intake

1. Sleep disturbance and anxiety

Would like to talk about his sleep
Several months of broken sleep, not getting enough, waking through the night, and unable to switch head off
Happens most nights
Goes to bed around 10:30, falls asleep within half an hour
Wakes 2 or 3 times a night, awake for half an hour to an hour each time
While awake at night, lies there thinking, sometimes anxious, staring at the ceiling waiting to drop off
Thoughts at night are mostly about work and relationship stuff; notes going through a rough patch with partner which keeps him up
Wakes up at 5 or 5:30, sometimes awake for good at 4
Gets about 6 hours of sleep on a typical night, which has been the case for the last year
Worrying is present during the day as well, mostly about work, replaying meetings and what he should have said
Works as an operations manager at a freight company, currently experiencing long days, high pressure, and a restructure
Some days has to sit in the car for ten minutes to settle down
During the day feels more tired, more on edge and restless, going over things in his head
Concentration drops off as the day goes on
Mood is lower, irritable one minute, flat the next
Hardly ever naps or dozes off during the day
Taking melatonin 2mg tablets, two at night, started 3 or 4 weeks ago — sleep still not great
Fluoxetine went up to 40mg in the mornings 3 or 4 weeks ago
Sleep was already bad before the medication changes
Denies thoughts of self-harm or suicide
Denies caffeine, alcohol, nicotine, or any other substances later in the day
Denies times of unusually high or irritable mood, much more energy, needing less sleep without feeling tired, rapid speech, or doing risky things

Background:
PMH:Anxiety
Medications:fluoxetine 40mg mane melatonin 4mg nocte
Allergies:Penicillin (Rash)
FHx:Mother has hypothyroidism father had stroke at age 70
Non-smoker EtOH: Stopped drinking a couple of years ago Recreational drugs: Nil other substances
Hospitalisations/surgeries:Knee arthroscopy
Mental health care:6 sessions with psychologist through work last year
Medication changes:Fluoxetine increased to 40mg in the mornings and started melatonin 4mg at night 3-4 weeks ago
Family mental health:Sister has anxiety
Living situation and supports:Lives with partner, has a couple of good friends

Sources (27)

[s0:1] Patient Want to talk about my sleep. Still not great - not enough of it, broken, waking through the night, can't switch my head off. I've been taking the melatonin before bed like I was told and went up to two tablets.

[s0:5] Patient Several months now.

[s0:7] Patient Most nights.

[s0:23] Patient Bed about 10:30, asleep within half an hour. Up at 5, 5:30. Some mornings I'm awake for good at 4.

[s0:9] Patient 2 or 3 times. Half an hour to an hour each time.

[s0:11] Patient Bit of all of it. I lie there thinking, sometimes anxious, staring at the ceiling waiting to drop off again.

[s0:13] Patient Work mostly. Relationship stuff.

[s0:51] Patient My partner. We've had a rough patch, which is some of what keeps me up, but we're working on it. A couple of good friends.

[s0:19] Patient About 6 hours. It's been around that for the last year really.

[s0:15] Patient During the day too. Work's the main one, I replay meetings and what I should have said. Some days I have to go sit in the car for ten minutes to settle down.

[s0:53] Patient Operations manager at a freight company. Long days and a lot of pressure at the moment, there's a restructure going on.

[s0:21] Patient More tired, more on edge and restless, going over things in my head. Concentration drops off as the day goes on, and my mood's lower - irritable one minute, flat the next.

[s0:25] Patient Hardly ever.

[s0:29] Patient Fluoxetine went up to 40mg in the mornings and I started the melatonin, 2mg tablets, two at night.

[s0:31] Patient Three or four weeks ago. The sleep was already bad before that.

[s0:16] Intake assistant Thank you. Have you had any thoughts of self-harm or suicide?

[s0:17] Patient No.

[s0:26] Intake assistant Thank you. Do you have caffeine, alcohol, nicotine, or any other substances, particularly later in the day?

[s0:27] Patient No, none of those.

[s0:32] Intake assistant Thank you. In the past few months, have you had times of unusually high or irritable mood, much more energy, needing less sleep without feeling tired, rapid speech, or doing risky things?

[s0:33] Patient No, not really.

[s0:35] Patient Anxiety, diagnosed about two years ago. Knee arthroscopy years back. Nothing else.

[s0:43] Patient Mum has an underactive thyroid. Dad had a stroke at 70.

[s0:47] Patient No. Never have.

[s0:49] Patient No. I stopped drinking a couple of years ago.

[s0:37] Patient Six sessions with a psychologist through work last year. Not seeing anyone at the moment.

[s0:45] Patient My sister has anxiety. That's all I know of.

Conversation transcript 57 turns

Audri turn 0

Hello, I'm Audri, your intake assistant. What brings you in for your upcoming appointment?

1 day ago

Patient turn 1

Want to talk about my sleep. Still not great - not enough of it, broken, waking through the night, can't switch my head off. I've been taking the melatonin before bed like I was told and went up to two tablets.

1 day ago

Audri turn 2

Thank you. Can you tell me your sex assigned at birth?

1 day ago

Patient turn 3

Male

1 day ago

Audri turn 4

Thank you. How long has your sleep been like this?

1 day ago

Patient turn 5

Several months now.

1 day ago

Audri turn 6

Is it happening every night, or only on some nights?

1 day ago

Patient turn 7

Most nights.

1 day ago

Audri turn 8

Thank you. When you wake during the night, how many times does it happen and how long are you awake for?

1 day ago

Patient turn 9

2 or 3 times. Half an hour to an hour each time.

1 day ago

Audri turn 10

Thank you. When you're awake, what's going on? For example, are you anxious or alert, thinking a lot, or uncomfortable?

1 day ago

Patient turn 11

Bit of all of it. I lie there thinking, sometimes anxious, staring at the ceiling waiting to drop off again.

1 day ago

Audri turn 12

What sorts of things are on your mind when you're lying awake?

1 day ago

Patient turn 13

Work mostly. Relationship stuff.

1 day ago

Audri turn 14

Thank you. Is the worrying only at night, or is it there during the day as well?

1 day ago

Patient turn 15

During the day too. Work's the main one, I replay meetings and what I should have said. Some days I have to go sit in the car for ten minutes to settle down.

1 day ago

Audri turn 16

Thank you. Have you had any thoughts of self-harm or suicide?

1 day ago

Patient turn 17

No.

1 day ago

Audri turn 18

Thank you. How much sleep are you getting on a typical night?

1 day ago

Patient turn 19

About 6 hours. It's been around that for the last year really.

1 day ago

Audri turn 20

How is it affecting you during the day?

1 day ago

Patient turn 21

More tired, more on edge and restless, going over things in my head. Concentration drops off as the day goes on, and my mood's lower - irritable one minute, flat the next.

1 day ago

Audri turn 22

What time do you go to bed and get up, and how long does it take you to fall asleep?

1 day ago

Patient turn 23

Bed about 10:30, asleep within half an hour. Up at 5, 5:30. Some mornings I'm awake for good at 4.

1 day ago

Audri turn 24

Do you nap or doze off during the day?

1 day ago

Patient turn 25

Hardly ever.

1 day ago

Audri turn 26

Thank you. Do you have caffeine, alcohol, nicotine, or any other substances, particularly later in the day?

1 day ago

Patient turn 27

No, none of those.

1 day ago

Audri turn 28

Thank you. Have there been any recent changes to your medications?

1 day ago

Patient turn 29

Fluoxetine went up to 40mg in the mornings and I started the melatonin, 2mg tablets, two at night.

1 day ago

Audri turn 30

When did those changes happen, compared with when the sleep problems started?

1 day ago

Patient turn 31

Three or four weeks ago. The sleep was already bad before that.

1 day ago

Audri turn 32

Thank you. In the past few months, have you had times of unusually high or irritable mood, much more energy, needing less sleep without feeling tired, rapid speech, or doing risky things?

1 day ago

Patient turn 33

No, not really.

1 day ago

Audri turn 34

Thank you. As this is your first Audri intake, I have a few extra questions to get your background history. Do you have any ongoing medical conditions or past surgeries?

1 day ago

Patient turn 35

Anxiety, diagnosed about two years ago. Knee arthroscopy years back. Nothing else.

1 day ago

Audri turn 36

Thank you. Have you had any care for your mental health, such as a psychologist, counsellor, or psychiatrist?

1 day ago

Patient turn 37

Six sessions with a psychologist through work last year. Not seeing anyone at the moment.

1 day ago

Audri turn 38

Thank you. Apart from the fluoxetine and melatonin, are you taking any other medications or supplements?

1 day ago

Patient turn 39

No.

1 day ago

Audri turn 40

Do you have any allergies to medications, foods, or anything else?

1 day ago

Patient turn 41

Penicillin. I get a rash.

1 day ago

Audri turn 42

Thank you. In your immediate family, do you have any history of heart disease, stroke, abnormal blood pressure or cholesterol, diabetes, or cancer?

1 day ago

Patient turn 43

Mum has an underactive thyroid. Dad had a stroke at 70.

1 day ago

Audri turn 44

Thank you. And in your family, has anyone had a mental health condition, such as depression, anxiety, or bipolar disorder, or died by suicide?

1 day ago

Patient turn 45

My sister has anxiety. That's all I know of.

1 day ago

Audri turn 46

Thank you. Do you smoke or vape?

1 day ago

Patient turn 47

No. Never have.

1 day ago

Audri turn 48

Do you consume alcohol, and if so, how often and how much?

1 day ago

Patient turn 49

No. I stopped drinking a couple of years ago.

1 day ago

Audri turn 50

Thank you. Who do you live with, and who do you have around you for support?

1 day ago

Patient turn 51

My partner. We've had a rough patch, which is some of what keeps me up, but we're working on it. A couple of good friends.

1 day ago

Audri turn 52

Thank you. What kind of work do you do, and how is it going?

1 day ago

Patient turn 53

Operations manager at a freight company. Long days and a lot of pressure at the moment, there's a restructure going on.

1 day ago

Audri turn 54

Thank you for that information. Is there anything else you would like to add or feel is important for the medical team to know?

1 day ago

Patient turn 55

No, I think that's it.

1 day ago

Audri turn 56

Thank you. The intake is now complete, and the information will be reviewed by the medical team. Thank you for speaking with me today.

1 day ago