SLEEP DIARY
You may print and fill in this Sleep Diary as a starting point for a conversation with your doctor about sleep.
You may print and fill in this Sleep Diary as a starting point for a conversation with your doctor about sleep.
First Name:
MI:
Last Name:
Sleep Diary Dates From: To:
Sleep Diary Dates From: To:
| 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: |
