SLEEP LOG
Please complete form for a period of one (1) week prior to your sleep study.
Name:
Day 1 2 3 4 5 6 7
Date
1. What time did you awaken?
2. Self or alarm?
3. Time you got out of bed?
4. Feel groggy or refreshed?
Did you nap today? If so, how
5. many times and how long?
6. Amount of exercise?
7. Amount of time worked?
8. How did you feel this day?
9. Any alcohol? Amount?
10. Time you went to bed?
11. Time to sleep?
How many times did you
12. awaken this night?
List medications taken and
13. the dosages and times you
took them.