Fill in the times and numbers below	First day	Second day	Third day	Fourth day
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)	____	____	____	____