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ASSESING YOUR SLEEP PATTERN: SLEEP DIARY

Maintain this diary regularly for the next three weeks. If you can do so without causing any disruption in your sleep routine, answer the following questions before going to sleep; if it suits your schedule better, answer them as soon as possible the next morning. Remember, record your answers in a notebook along with the responses to the first two questionnaires.

Coffee consumption (before 6 P.M.): Coffee consumption (after 6 P.M.): Cigarettes (before 6 P.M.): Cigarettes (after 6 P.M.): Alcohol consumption (before 6 P.M.): Alcohol consumption (after 6 P.M.):

Prescription and over-the-counter medication (before 6 P.M.): Prescription and over-the-counter medication (after 6 P.M.): General ability to function, A.M. (scale 1-10): General concentration, A.M. (scale 1-10):

General ability to function, P.M. (scale 1-10):

General concentration, P.M. (scale 1-10):

Describe any daytime sleepiness (intensity, time of day, etc.):

Stressful events: Describe:

Emotional events: Describe:

General mood during the day:

Naps: Number, time of day, total time today:

Total twenty-four-hour sleep time including naps:

Exercise: Regimen, time of day: /

Dinnertime:

Snacks since dinner (including when eaten):

Activities from dinner to bedtime:

Presleep ritual: Describe:

Any sleeping pills? Describe:

Time you got into bed:

Bedtime mood (anxious, happy, etc.):

Sleepiness (scale 1-10):

Answer these questions on rising:

Time of waking: Time of rising:

Approximate time you fell asleep:

Total hours in bed:

Total hours asleep:

Awaken before or with alarm?

Wakenings: Number:

Total time awake:

What did you do if awake? Quality of sleep (scale 1-10) Energy level on rising (scale 1-10)

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