"Sleep Log Template"

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Sleep Log
Name:
Example
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Week (beginning date to ending date):
Day 1
Fill out 1-6 prior to going to bed
1) I napped from _____ to ______ (note times of all naps
2:00 to 2:45 pm
2) I took _____ mg of sleep medication as a sleep aid
Prosom 1 mg
3) I took ____ oz of alcohol as a sleep aid
beer 12 oz
4) I went to bed at _____ o'clock
10:30
5) I turned the lights out at _____ o'clock
11:15
6) I plan to awaken at _____ o'clock
0
Fill out 7-13 the next day
7) After turning the lights out, I fell asleep in ___ minutes
45
8) My sleep was interrupted ____ times (specify numer of nighttime
awakenings)
3
9) My sleep was interrupted for ______ minutes (specify duration of each
awakening)
20, 30, 15
10) I woke up at _____ o'clock (note time of last awakening)
6:15
11) I got out of bed at _____ o'clock (specify the time)
6:40
12) When I got up this morning I felt_______.
2
(1=exhausted, 2=tired, 3=average, 4=rather refreshed, 5=very refreshed)
13) Overall, my sleep last night was _______.
(1=very restless, 2=restless, 3=average, 4==sound, 5=very sound)
1
Sleep Log
Name:
Example
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Week (beginning date to ending date):
Day 1
Fill out 1-6 prior to going to bed
1) I napped from _____ to ______ (note times of all naps
2:00 to 2:45 pm
2) I took _____ mg of sleep medication as a sleep aid
Prosom 1 mg
3) I took ____ oz of alcohol as a sleep aid
beer 12 oz
4) I went to bed at _____ o'clock
10:30
5) I turned the lights out at _____ o'clock
11:15
6) I plan to awaken at _____ o'clock
0
Fill out 7-13 the next day
7) After turning the lights out, I fell asleep in ___ minutes
45
8) My sleep was interrupted ____ times (specify numer of nighttime
awakenings)
3
9) My sleep was interrupted for ______ minutes (specify duration of each
awakening)
20, 30, 15
10) I woke up at _____ o'clock (note time of last awakening)
6:15
11) I got out of bed at _____ o'clock (specify the time)
6:40
12) When I got up this morning I felt_______.
2
(1=exhausted, 2=tired, 3=average, 4=rather refreshed, 5=very refreshed)
13) Overall, my sleep last night was _______.
(1=very restless, 2=restless, 3=average, 4==sound, 5=very sound)
1