Professional Documents
Culture Documents
Ref: AE/
Date:
Name:
Address:
Dear
To help us understand your sleep problems we would like you to keep a sleep diary for the
next _____ days.
Using the options listed on the diary please report your daily activities and sleep experience
in the spaces provided.
The diary should be kept by the bedside and the relevant information charted before and
after bedtime each day. Behind the weekly log is a page for your comments, which you think
important.
If you have any queries please telephone the department on the above number.
IT IS IMPORTANT THAT YOU KEEP THIS DIARY FOR THE NEXT _____ DAYS
Yours sincerely
Daytime/Evening Activities
A= Alcohol
E= Exercise
M= Medication
N= Naps
Sleep Experience
P= Pain
T= Toilet
W= Worry
Medications:
Please list all medications taken together with amounts:-
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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SLEEP DIARY
NAME:_________________________________
DATE OF BIRTH:________________________
Example 1 2 3 4 5 6 7
Day Monday
Date 1/01/01
Total sleep 4h
Estimated
time to fall
45mins
asleep
Awakenings x2
& Times 2am/3am
Final wake
6:30am
Time
Toilet during
2
night
Caffeine
13
drinks
Day/Eve
A S U
activities
Sleep
W T
experience
2
10am train
Naps-Time,
15mins
where, how
8pm Chair
long
at home
10mins
COMMENTS
1. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
6. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
7. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________