PATIENT'S NAME:__________________________                DATE OF BIRTH: __________________________ | WEEK STARTS ON:___/____/______ | WEEK ENDS ON:___/____/______
WEEKLY SLEEP LOG | EXAMPLE | MONDAY | TUESDAY | WEDNESDAY | THURSDAY | FRIDAY | SATURDAY | SUNDAY | AVERAGE
BEDTIME | 10 P.M. | | | | | | | |
LIGHTS-OUT TIME | 11 P.M. | | | | | | | |
HOW LONG DID IT TAKE TO FALL ASLEEP (IN MINUTES)? | 30 | | | | | | | |
HOW MANY TIMES DID YOU WAKE UP AT NIGHT? | 3 | | | | | | | |
HOW LONG DID YOU STAY AWAKE AT NIGHT OVERALL? | 1 HOUR | | | | | | | |
WHAT WAS YOUR FINAL AWAKENING IN THE MORNING? | 6 A.M. | | | | | | | |
WHEN DID YOU GET OUT OF BED? | 7 A.M. | | | | | | | |
TOTAL SLEEP TIME AT NIGHT * | | | | | | | | |
SLEEP EFFICIENCY* | | | | | | | | |
WHEN DID YOU NAP DURING THE DAY? | 1-2 P.M. | | | | | | | |
HOW MANY ALCOHOLIC BEVERAGES DID YOU DRINK AND WHEN? | NONE | | | | | | | |
HOW MANY CAFFEINATED BEVERAGES DID YOU DRINK AND WHEN? | THREE: 7 A.M., 8 A.M., 2 P.M. | | | | | | | |
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* THESE WILL BE CALCULATED BY THE EXAMINER | | | | | |
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