Sleep Diary

Start tracking your sleep patterns today — it's easy! This diary will give you a clear "snapshot" of your sleep patterns to share with your healthcare provider. These patterns will help your healthcare provider learn about the quality of your sleep and how it affects you each day. This information may help your healthcare provider diagnose your problem and recommend ways to help restore a healthy sleep cycle. Please select [PRINT] from the [FILE] menu or use PDF to print this diary.

  Sleep Diary

1. Print this page.
2. Answer the first six questions each day in the morning when you wake to start your day.
3. Answer the remaining three questions each night before bedtime.
4. Enter your answers consistently for seven days.
5. Share the completed diary with your physician.

ANSWER IN THE MORNING AFTER WAKING FOR THE DAY
	At what time did you first go to bed last night?	Approximately how long did it take you to fall asleep?	About how many times, if any, did you awaken during the night?	Overall, about how many hours did you sleep?	At what time did you wake up (for the last time) this morning?	In general, how did you feel when you woke up?
DAY 1						Very refreshed Somewhat refreshed Fatigued
DAY 2						Very refreshed Somewhat refreshed Fatigued
DAY 3						Very refreshed Somewhat refreshed Fatigued
DAY 4						Very refreshed Somewhat refreshed Fatigued
DAY 5						Very refreshed Somewhat refreshed Fatigued
DAY 6						Very refreshed Somewhat refreshed Fatigued
DAY 7						Very refreshed Somewhat refreshed Fatigued

ANSWER AT BEDTIME JUST BEFORE YOU GO TO SLEEP
	How much time, if any, did you spend napping during the day?	Did you consume any of these substances during the day?	On a scale of one to five, how would you rate your overall functioning during the day?
DAY 1		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 - Energetic 4 3 2 1 - Lethargic
DAY 2		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 - Energetic 4 3 2 1 - Lethargic
DAY 3		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 -Energetic 4 3 2 1 - Lethargic
DAY 4		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 - Energetic 4 3 2 1 - Lethargic
DAY 5		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 - Energetic 4 3 2 1 - Lethargic
DAY 6		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 - Energetic 4 3 2 1 - Lethargic
DAY 7		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 - Energetic 4 3 2 1 - Lethargic