Sleep Diary Form

SLEEP DIARY

 COMPLETE THIS SECTION AFTER GETTING OUT OF BED 

 COMPLETE AT END OF NEXT DAY 

Time it took

*Amount

Time you

Total

Sleepiness

Fatigue

Napping:

Day &

Unusual stressors, time of

Time you

you to fall

# of

of time

got up for

sleep

Rating

Rating

time of day &

Date

alcohol & sleep medications

went to bed

asleep

awakenings

awake

the day

time

(see below)

(see below)

sleep amount

Sunday

argument at dinner, 2 beers 6-

3pm

10pm

30 min

3

30 min

6am

7 hr

75

45

4/08/12

8pm, Ambien 10 mg at 9:30pm

1 hr

* Amount of time awake: this is all the time you spent awake during the night, from the first time you awakened to the time you got out of bed. It does not include the time it

took you to fall asleep initially

SLEEPINESS AND FATIGUE RATING SCALE: (AVERAGE RATING FOR THE WHOLE DAY FOLLOWING A GIVEN SLEEP EPISODE)

0

25

50

75

...100

SLEEPINESS:

Extremely sleepy

Sleepy

Neither

Alert

Very alert

<

>

FATIGUE:

Extremely fatigued

Fatigued

Neither

Energetic

Very energetic