Cognitive Behavioral Therapy For Insomnia (Cbti) Program Sleep Diary
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1Cognitive Behavioral Therapy for Insomnia (CBTI) Program Sleep Diary (Please complete upon awakening )
NAME: ______________________
Today's Date
___/___/___
___/___/___
___/___/___
___/___/___
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1. List any sleep aids you took.
Medication(s)
Medication(s)
Medication(s)
Medication(s)
Medication(s)
Medication(s)
Medication(s)
& Dose:
& Dose:
& Dose:
& Dose:
& Dose:
& Dose:
& Dose:
Time(s) taken: Time(s) taken: Time(s) taken: Time(s) taken: Time(s) taken: Time(s) taken: Time(s) taken:
2. What time did you get into bed?
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
3. What time did you try to go to sleep?
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
4. How long did it take you to fall asleep?
_____hour(s)
_____hour(s)
_____hour(s)
_____hour(s)
_____hour(s)
_____hour(s)
_____hour(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
5. How many times did you wake up
_____times
_____times
_____times
_____times
_____times
_____times
_____times
in the night?
6. In total, how long did these
_____hour(s)
_____hour(s)
_____hour(s)
_____hour(s)
_____hour(s)
_____hour(s)
_____hour(s)
awakenings last?
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
7. What time did you finally awaken
___:___ AM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
for the day?
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ PM
7a. Did you wake up earlier than you
No/Yes
No/Yes
No/Yes
No/Yes
No/Yes
No/Yes
No/Yes
planned? If so, by how much?
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
7b. Did you wake up later than you
No/Yes
No/Yes
No/Yes
No/Yes
No/Yes
No/Yes
No/Yes
planned? If so, by how much?
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
8. What time did you get out of bed for
___:___ AM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
___:___ AM
the day?
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ PM
___:___ PM
9. In total, how long did you sleep?
_____hour(s)
_____hour(s)
_____hour(s)
_____hour(s)
_____hour(s)
_____hour(s)
_____hour(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
10. What was the quality of your sleep?
(1=very poor … 5=very good)
11. How rested or refreshed do you feel?
(1=not at all rested … 5=well rested)
12. How long did you nap yesterday?
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
_____min(s)
13. Comments (if applicable):
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