Sleep diary

Day: __ Date: __ Patient ID:

Complete before bedtime:

1. Time actigraph removed for bathing: __ : __ am/pm

Time put back on: __ : __ am/pm

2. How many naps did you take today?

Times: From: __ : __ am/pm  To: __ : __ am/pm

From: __ : __ am/pm  To: __ : __ am/pm

3. How many cups of coffee or other beverages with caffeine did you drink?

Times: __ : __ am/pm

           __ : __ am/pm

4. How many alcoholic beverages did you drink?

Time: __ : __ am/pm

         __ : __ am/pm

Complete in the morning:

1. What time did you go to bed? __ : __ am/pm

2. What time did you turn out the lights and go to sleep? __ : __ am/pm

3. How long did it take you to fall asleep? __ hours and __ minutes

4. How many awakenings did you have during the night?

5. What time did you wake up in the morning? __ : __ am/pm

6. What time did you get out of bed? __ : __ am/pm

7. Did you feel refreshed when you got up? yes/no