Neftaly Medical Certificate

Patient Name: ____________________________
Date of Birth: ____________________________
Gender: _________________________________

Date of Examination: ______________________
Certificate Issued On: ______________________

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Medical Diagnosis:

Insomnia (Sleep Disorder)
ICD-10 Code: G47.0 – Insomnia, unspecified

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Clinical Findings:

The patient presented with clinical symptoms consistent with insomnia, including:

• Difficulty initiating or maintaining sleep
• Non-restorative or poor-quality sleep
• Daytime fatigue and irritability
• Impaired concentration and cognitive function
• Reported sleep duration: ___________ hours per night

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Assessment and Management:

• Clinical assessment of sleep patterns and contributing factors
• Education on sleep hygiene practices
• Lifestyle modification and stress management advice
• Trial of short-term pharmacological or non-pharmacological interventions (if appropriate)
• Referral for psychological support or sleep study (if indicated)

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Prognosis:

Insomnia may affect the patient’s cognitive function, alertness, and general well-being. Time off from work or school may be necessary to allow for rest, treatment adherence, and recovery. Continued monitoring is recommended.

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Medical Certificate Statement:

This is to certify that the above-named patient has been diagnosed with Insomnia and is currently under medical care at Neftaly Medical Center.
The patient is deemed medically unfit for work/school from:
_________________ to _________________
Expected return to normal activities: _________________, subject to reassessment and clinical progress.

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Attending Physician: _________________________
Medical License Number: _____________________
Signature & Official Stamp: ___________________