Sleep Diary

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First Name:______________  MI:___     Last Name:_______________
Sleep Diary Dates  From: _____  To: _____

Our doctors will want you to keep a sleep diary for at least two weeks before diagnosing you with a circadian sleep disorder, or referring you to a specialist. You can print this one out to help you in this. Just use the Print function in your web browser (usually found under the File menu).

  Mon Tues Wed Thu Fri Sat Sun
What time did you first go to bed yesterday?              
What time did you get to sleep?              
About how many times, if any, did you awaken during the night?              
On a scale of 1 (poor sleep, trouble sleeping at all) to 5 (slept like a baby), how would you rate the quality of your sleep this time?              
Overall, about how many hours did you sleep?              
At what time did you wake up (for the last time) today?              
In general, how did you feel when you woke up? (refreshed? tired?)
              
How much time, if any, did you spend napping during the day?              
Did you consume any of these substances during the day?
  • Caffeine less than 6 hrs before bedtime
  • Alcohol less than 1 hr before bedtime
  • Medication (including melatonin and other sleep aids)
             
On a scale of 1 (depressed, lethargic) to 5 (positive, energetic), how would you rate your mood and overall functioning during the day?              
What sort of exercise did you do today, and when?              
Additional comments you think would be relevant: