Sleep Diary Template

SleepCare
Sisters of Charity Hospital
St. Joseph Campus
2605 Harlem Road
Cheektowaga, NY 14225
SLEEP DIARY
Patient’s Name__________________________________ Appt. Date: ___________ Please start on: __________
WEEK 1
QUESTION EXAMPLE DAY 1
Date:
What time did you go to bed 11:00 PM
How long did it take to fall 45 min.
asleep
What time did you wake up 6:00 AM
this morning
How many times did you Twice
wake
up during the night
How many hours of sleep did 6 ½ hours
you get last night
Rate your sleep on a scale 6
of 1-10
(10 is completely refreshed)
Did you have a nap today
How long did you sleep
Did you have caffeine
(coffee/cola) How much
Did you have alcohol today
How much
Rate how alert you are on a
scale of 1-10
(10 is completely alert)
Yes, 60
minutes
Yes, 2 cups
of coffee
One beer
with dinner
4
DAY 2
Date:
DAY 3
Date:
DAY 4
Date:
DAY 5
Date:
DAY6
Date:
DAY 7
Date:

SleepCare
St. Joseph Campus
SLEEP DIARY
Patient’s Name__________________________________
WEEK 2
QUESTION EXAMPLE DAY 1
Date:
What time did you go to bed 11:00 PM
How long did it take to fall 45 min.
asleep
What time did you wake up 6:00 AM
this morning
How many times did you Twice
wake
up during the night
How many hours of sleep did 6 ½ hours
you get last night
Rate your sleep on a scale 6
of 1-10
(10 is completely refreshed)
Did you have a nap today
How long did you sleep
Did you have caffeine
(coffee/cola) How much
Did you have alcohol today
How much
Rate how alert you are on a
scale of 1-10
(10 is completely alert)
Yes, 60
minutes
Yes, 2 cups
of coffee
One beer
with dinner
4
DAY 2
Date:
DAY 3
Date:
DAY 4
Date:
DAY 5
Date:
DAY6
Date:
DAY 7
Date: