You may print and fill in this Sleep Diary as a starting point for a conversation with your doctor about sleep.
First Name:      MI:      Last Name:

Sleep Diary Dates                  From:      To:

What time did you first go to bed yesterday?
What time did you get to sleep?
About how many times, if any, did you awaken during the night?
On a scale of 1 (poor sleep, trouble sleeping at all) to 5 (slept like a baby), how would you rate the quality of your sleep this time?
Overall, about how many hours did you sleep?
At what time did you wake up (for the last time) today?
In general, how did you feel when you woke up? (refreshed? tired?)
How much time, if any, did you spend napping during the day?
Did you consume any of these substances during the day?

- Caffeine less than 6 hrs before bedtime
- Alcohol less than 1 hr before bedtime
- Medication (including melatonin and other sleep aids)
On a scale of 1 (depressed, lethargic) to 5 (positive, energetic), how would you rate your mood and overall functioning during the day?
What sort of exercise did you do today, and when?
Additional comments you think would be relevant:
Sleep Questionnaire
Do you snore or wake up tired?
Do you have high blood pressure?
Do you have a weight problem?
Are you depressed?
Are you forgetful?