Sleep/wake Chart
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1
2COMMUNITY HEALTH NETWORK
SLEEP/WAKE DISORDERS CENTER
SLEEP/WAKE CHART
YOUR NAME: ________________________________________
EACH MORNING DO THE FOLLOWING:
1. WRITE IN DATES (SEE EXAMPLE)
2. MARK EACH TIME OF GETTING INTO BED WITH “!”
3. MARK PERIODS OF SLEEP AS SHADED AREAS BETWEEN VERTICAL BARS “///////”
4. MARK EACH TIME OF GETTING OUT OF BED WITH “"”
5. MARK ALL DAYTIME NAPS THE SAME WAY.
6. ANSWER ALL 8 QUESTIONS
Mid-
DAY & DATE
1
2
3
4
5
6
7
8
6PM 7PM 8PM 9PM 10PM 11PM
Night
1AM 2AM 3AM 4AM 5AM 6AM 7AM 8AM
9AM 10AM 11AM NOON 1PM 2PM 3PM 4PM 5PM
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3
1 2 3
1 2 3 4
1 2 1 2
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3
1 2 3
1 2 3 4
1/20 - 21/94
EXAMPLE
No
7 hr
6 AM
C
4
Yes
8 AM 6 PM
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3
1 2 3
1 2 3 4
1 2 1 2
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3 4 5
1 2 3 4
1 2 3
1 2 3
1 2 3 4
NRLGY17 Rev. 1193 ESI#12242
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