| Complete in the morning | | | | |
| Bedtime (date/time) | ____ | ____ | ____ | ____ |
| Rise time (date/time) | ____ | ____ | ____ | ____ |
| Estimated time to fall asleep | ____ | ____ | ____ | ____ |
| Estimated number of awakenings and total time awake | ____ | ____ | ____ | ____ |
| Estimated amount of sleep obtained | ____ | ____ | ____ | ____ |
| Complete at bedtime | | | | |
| Naps (number, time, and duration) | ____ | ____ | ____ | ____ |
| Alcoholic drinks consumed (number and time) | ____ | ____ | ____ | ____ |
| Stresses of the day (list) | ____ | ____ | ____ | ____ |
| Rate how you felt today: 1 = very tired/ sleepy, 2 = somewhat tired/sleepy, 3 = fairly alert, 4 = wide awake | ____ | ____ | ____ | ____ |
| Rate your irritability level: 1 = none, 2 = some, 3 = moderate, 4 = fairly high, 5 = high | ____ | ____ | ____ | ____ |
| Medications (list) | ____ | ____ | ____ | ____ |
