"Two Week Sleep Diary Form"

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TWO WEEK SLEEP DIARY
INSTRUCTIONS:
1.
Write the date, day of the week, and type of day: Work, School, Day Off, or Vacation.
2.
Put the letter “C” in the box when you have coffee, cola or tea. Put “M” when you take any medicine. Put “A” when you drink
alcohol. Put “E” when you exercise.
3.
Put a line (l) to show when you go to bed. Shade in the box that shows when you think you fell asleep.
4.
Shade in all the boxes that show when you are asleep at night or when you take a nap during the day.
5.
Leave boxes unshaded to show when you wake up at night and when you are awake during the day.
SAMPLE ENTRY BELOW: On a Monday when I worked, I jogged on my lunch break at 1 PM, had a glass of wine with dinner at 6 PM, fell asleep watching TV from 7 to 8 PM, went to bed at
10:30 PM, fell asleep around Midnight, woke up and couldn’t got back to sleep at about 4 AM, went back to sleep from 5 to 7 AM, and had coffee and medicine at 7:00 in the morning.
Day of
Type of Day
Today’s
the
Work, School,
Date
week
Off, Vacation
C
sample
Mon.
Work
E
A
I
M
TWO WEEK SLEEP DIARY
INSTRUCTIONS:
1.
Write the date, day of the week, and type of day: Work, School, Day Off, or Vacation.
2.
Put the letter “C” in the box when you have coffee, cola or tea. Put “M” when you take any medicine. Put “A” when you drink
alcohol. Put “E” when you exercise.
3.
Put a line (l) to show when you go to bed. Shade in the box that shows when you think you fell asleep.
4.
Shade in all the boxes that show when you are asleep at night or when you take a nap during the day.
5.
Leave boxes unshaded to show when you wake up at night and when you are awake during the day.
SAMPLE ENTRY BELOW: On a Monday when I worked, I jogged on my lunch break at 1 PM, had a glass of wine with dinner at 6 PM, fell asleep watching TV from 7 to 8 PM, went to bed at
10:30 PM, fell asleep around Midnight, woke up and couldn’t got back to sleep at about 4 AM, went back to sleep from 5 to 7 AM, and had coffee and medicine at 7:00 in the morning.
Day of
Type of Day
Today’s
the
Work, School,
Date
week
Off, Vacation
C
sample
Mon.
Work
E
A
I
M