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SLEEP DIARY
Use this to compile data on your sleep quality and habits. Once completed, you should bring when going to see your doctor. The more information available to your doctor, the more effective they can be in dealing with your sleep problems.
| NAME | |
| AGE | |
| HEIGHT
WEIGHT |
|
| MEDICATIONS BEING TAKEN | |
| OTHER MEDICAL CONDITIONS |
| Start Date | Mon | Tues | Wed | Thurs | Fri | Sat | Sun |
| Time I went to bed last night
Time I woke up this morning
Number of hours’ sleep |
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| Number of awakenings
Approx. total time awake |
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| How long it took me to fall asleep | |||||||
| How awake did I feel on awakening this morning?
1. Wide awake 2. Awake, but a little tired 3. Tired/sleepy |
| Number of caffeinated/fizzy or alcoholic drinks taken today | |||||||
| Time of last drink | |||||||
| Any naps? (number and length of time) | |||||||
| Any exercise (amount of time) | |||||||
| How sleepy I felt during the day
Struggled to stay awake (1) Somewhat tired (2) Fairly alert (3) Wide awake (4) |
The Sleep Diary is completed in 3 blocks.
First block relates to detail about you. Fill in as much detail as possible, and if necessary continue to a separate sheet of paper. The more detail the better.
Second Block relates to your actual sleep. It should be completed on the morning after sleep (Monday night’s sleep detail, complete on Tuesday morning).
Third Block relates to issues that might affect your sleep (Monday’s detail should be completed before going to bed on Monday night).
The Sleep Diary is a subjective report on YOUR SLEEP. To get the maximum benefit, you must insert truthful information. It helps to determine a realistic baseline from which to start off.
ANSWERS MAY BE EXTENDED TO ANOTHER SHEET OF PAPER.