Athens Center for Sleep Disorders Sleep Diary

    

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Athens Sleep Center Sleep Diary
COMPLETE IN MORNING
 

Athens Sleep Center Sleep Diary

COMPLETE AT END OF DAY
(903)
675-1717		 I went to bed last night at: I got out of bed this morning at: Last night, I fell asleep in: I woke up during the night: When I woke up for the day I felt: Last night I slept a total of: My sleep was disturbed by: (List any mental, emotional,  (903)
675-1717		 I consumed caffeinated drinks in the: I exercised at least 20 minutes in the: Approximately 2-3 hours before going to bed, I consumed: Medication(s) I took during the day: About 1 hour before going to sleep, I did the following activity:
      (Record number of times) (Circle one) (Record number of hours) physical or environmental factors that affected your sleep; e.g. stress, snoring, physical discomfort, temperature) (e.g. coffee, tea, cola)  (circle all that aply)   (List name of medication/drug(s)) (List activity; e.g. watch TV, work, read)
DAY 1

Day_____ 

Date____		 ________  AM/PM ________  AM/PM ________ Minutes _______  Times Refreshed

Somewhat refreshed

Fatigued		 ______ Hours _________________
_________________
_________________
_________________		 DAY 1

Day_____ 

Date____		 Morning
Afternoon
Within several hours
before going to bed
Not applicable		 Morning
Afternoon
Within several hours
before going to bed
Not applicable		 Alcohol
A heavy meal
Not applicable		 _________________
_________________
_________________
_________________		 _________________
_________________
_________________
_________________
DAY2 

Day_____

Date____		 ________  AM/PM ________  AM/PM ________ Minutes _______  Times Refreshed

Somewhat refreshed

Fatigued		 ______ Hours _________________
_________________
_________________
_________________		 DAY2 

Day_____

Date____		 Morning
Afternoon
Within several hours
before going to bed
Not applicable		 Morning
Afternoon
Within several hours
before going to bed
Not applicable		 Alcohol
A heavy meal
Not applicable		 _________________
_________________
_________________
_________________		 _________________
_________________
_________________
_________________
DAY 3

Day_____

Date____		 ________  AM/PM ________  AM/PM ________ Minutes _______  Times Refreshed

Somewhat refreshed

Fatigued		 ______ Hours _________________
_________________
_________________
_________________		 DAY 3

Day_____

Date____		 Morning
Afternoon
Within several hours
before going to bed
Not applicable		 Morning
Afternoon
Within several hours
before going to bed
Not applicable		 Alcohol
A heavy meal
Not applicable		 _________________
_________________
_________________
_________________		 _________________
_________________
_________________
_________________
DAY 4

Day_____

Date____		 ________  AM/PM ________  AM/PM ________ Minutes _______  Times Refreshed

Somewhat refreshed

Fatigued		 ______ Hours _________________
_________________
_________________
_________________		 DAY 4

Day_____

Date____		 Morning
Afternoon
Within several hours
before going to bed
Not applicable		 Morning
Afternoon
Within several hours
before going to bed
Not applicable		 Alcohol
A heavy meal
Not applicable		 _________________
_________________
_________________
_________________		 _________________
_________________
_________________
_________________
DAY 5 

Day_____

Date____		 ________  AM/PM ________  AM/PM ________ Minutes _______  Times Refreshed

Somewhat refreshed
 
Fatigued		 ______ Hours _________________
_________________
_________________
_________________		 DAY 5 

Day_____

Date____		 Morning
Afternoon
Within several hours
before going to bed
Not applicable		 Morning
Afternoon
Within several hours
before going to bed
Not applicable		 Alcohol
A heavy meal
Not applicable		 _________________
_________________
_________________
_________________		 _________________
_________________
_________________
_________________