"Sleep Diary Form - Tri-State"

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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
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