Sleep Diary for McLaren Greater Lansing

McLaren-Greater Lansing Sleep Diary

Please fill this form out the WEEK PRIOR to your appointment. Bring this completed form with you to the McLaren-Greater Lansing Center for Sleep and Alertness on your scheduled appointment date.

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Note: Fields marked with an * indicates required field

Name: *

Mondays Date starting the day of your diary: *

Monday

After turning the lights off last night I fell asleep in _____ minutes. example 40: *

[

My sleep last night was interrupted _____ times. (Specify number of nighttime awakenings.) example 3: *

My sleep last night was interrupted for ____ minutes. (Specify duration of each awakening.) example 10 5 45: *

This morning, I woke up at _____ oclock. (Note time of last awakening.) example 6:15 a.m.: *

This morning, I got out of bed at ______ oclock. (Specify the time.) example 6:40 a.m.: *

When I got up this morning, I felt _____ . (1 = Very Good 5 = Very Bad) example 2: *

Overall, my sleep last night was _____. (1 = Very Restless 5 = Very Sound) example 3: *

Today, I napped from _____ to . (Note the times of all naps.) 1:50 p.m. - 2:30 p.m.: *

Today, I took _____ mg of medication and/or _____ oz of alcohol as sleep aid. example aspirin 500 mg: *

Today I went to bed and turned the lights off at _____ oclock. example 11:15 p.m.: *

Tuesday

After turning the lights off last night I fell asleep in _____ minutes. example 40: *

[

My sleep last night was interrupted _____ times. (Specify number of nighttime awakenings.) example 3: *

My sleep last night was interrupted for ____ minutes. (Specify duration of each awakening.) example 10 5 45: *

This morning, I woke up at _____ oclock. (Note time of last awakening.) example 6:15 a.m.: *

This morning, I got out of bed at ______ oclock. (Specify the time.) example 6:40 a.m.: *

When I got up this morning, I felt _____ . (1 = Very Good 5 = Very Bad) example 2: *

Overall, my sleep last night was _____. (1 = Very Restless 5 = Very Sound) example 3: *

Today, I napped from _____ to . (Note the times of all naps.) 1:50 p.m. - 2:30 p.m.: *

Today, I took _____ mg of medication and/or _____ oz of alcohol as sleep aid. example aspirin 500 mg: *

Today I went to bed and turned the lights off at _____ oclock. example 11:15 p.m.: *

Wednesday

After turning the lights off last night I fell asleep in _____ minutes. example 40: *

[

My sleep last night was interrupted _____ times. (Specify number of nighttime awakenings.) example 3: *

My sleep last night was interrupted for ____ minutes. (Specify duration of each awakening.) example 10 5 45: *

This morning, I woke up at _____ oclock. (Note time of last awakening.) example 6:15 a.m.: *

This morning, I got out of bed at ______ oclock. (Specify the time.) example 6:40 a.m.: *

When I got up this morning, I felt _____ . (1 = Very Good 5 = Very Bad) example 2: *

Overall, my sleep last night was _____. (1 = Very Restless 5 = Very Sound) example 3: *

Today, I napped from _____ to . (Note the times of all naps.) 1:50 p.m. - 2:30 p.m.: *

Today, I took _____ mg of medication and/or _____ oz of alcohol as sleep aid. example aspirin 500 mg: *

Today I went to bed and turned the lights off at _____ oclock. example 11:15 p.m.: *

Thursday

After turning the lights off last night I fell asleep in _____ minutes. example 40: *

[

My sleep last night was interrupted _____ times. (Specify number of nighttime awakenings.) example 3: *

My sleep last night was interrupted for ____ minutes. (Specify duration of each awakening.) example 10 5 45: *

This morning, I woke up at _____ oclock. (Note time of last awakening.) example 6:15 a.m.: *

This morning, I got out of bed at ______ oclock. (Specify the time.) example 6:40 a.m.: *

When I got up this morning, I felt _____ . (1 = Very Good 5 = Very Bad) example 2: *

Overall, my sleep last night was _____. (1 = Very Restless 5 = Very Sound) example 3: *

Today, I napped from _____ to . (Note the times of all naps.) 1:50 p.m. - 2:30 p.m.: *

Today, I took _____ mg of medication and/or _____ oz of alcohol as sleep aid. example aspirin 500 mg: *

Today I went to bed and turned the lights off at _____ oclock. example 11:15 p.m.: *

Friday

After turning the lights off last night I fell asleep in _____ minutes. example 40: *

[

My sleep last night was interrupted _____ times. (Specify number of nighttime awakenings.) example 3: *

My sleep last night was interrupted for ____ minutes. (Specify duration of each awakening.) example 10 5 45: *

This morning, I woke up at _____ oclock. (Note time of last awakening.) example 6:15 a.m.: *

This morning, I got out of bed at ______ oclock. (Specify the time.) example 6:40 a.m.: *

When I got up this morning, I felt _____ . (1 = Very Good 5 = Very Bad) example 2: *

Overall, my sleep last night was _____. (1 = Very Restless 5 = Very Sound) example 3: *

Today, I napped from _____ to . (Note the times of all naps.) 1:50 p.m. - 2:30 p.m.: *

Today, I took _____ mg of medication and/or _____ oz of alcohol as sleep aid. example aspirin 500 mg: *

Today I went to bed and turned the lights off at _____ oclock. example 11:15 p.m.: *

Saturday

After turning the lights off last night I fell asleep in _____ minutes. example 40: *

[

My sleep last night was interrupted _____ times. (Specify number of nighttime awakenings.) example 3: *

My sleep last night was interrupted for ____ minutes. (Specify duration of each awakening.) example 10 5 45: *

This morning, I woke up at _____ oclock. (Note time of last awakening.) example 6:15 a.m.: *

This morning, I got out of bed at ______ oclock. (Specify the time.) example 6:40 a.m.: *

When I got up this morning, I felt _____ . (1 = Very Good 5 = Very Bad) example 2: *

Overall, my sleep last night was _____. (1 = Very Restless 5 = Very Sound) example 3: *

Today, I napped from _____ to . (Note the times of all naps.) 1:50 p.m. - 2:30 p.m.: *

Today, I took _____ mg of medication and/or _____ oz of alcohol as sleep aid. example aspirin 500 mg: *

Today I went to bed and turned the lights off at _____ oclock. example 11:15 p.m.: *

Sunday

After turning the lights off last night I fell asleep in _____ minutes. example 40: *

[

My sleep last night was interrupted _____ times. (Specify number of nighttime awakenings.) example 3: *

My sleep last night was interrupted for ____ minutes. (Specify duration of each awakening.) example 10 5 45: *

This morning, I woke up at _____ oclock. (Note time of last awakening.) example 6:15 a.m.: *

This morning, I got out of bed at ______ oclock. (Specify the time.) example 6:40 a.m.: *

When I got up this morning, I felt _____ . (1 = Very Good 5 = Very Bad) example 2: *

Overall, my sleep last night was _____. (1 = Very Restless 5 = Very Sound) example 3: *

Today, I napped from _____ to . (Note the times of all naps.) 1:50 p.m. - 2:30 p.m.: *

Today, I took _____ mg of medication and/or _____ oz of alcohol as sleep aid. example aspirin 500 mg: *

Today I went to bed and turned the lights off at _____ oclock. example 11:15 p.m.: *

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