Sleep Journal 2017

Name SUID #:
TA Name
Sleep Journal Number: Dates (mm/dd/year mm/dd/year)
Sleep Data: All times should be input in 12- hour XX:XX AM/PM format
A. B. C. D. E. F. G. H. I. J. K. L.
Day & Date Time in Fell Asleep Awoke At Time out of bed Time awake in middle Time awake in Time asleep at Time spent Total Time Asleep Extent of morning How you felt overall
Bed At of night (h) bed (h) night (h) napping (h) [H+I] (h) grogginess (min) today (1-10)
M

Tu
W
Th
F
Sa
Su
V. Weekly
Averages
(B- K)
Epworth Sleepiness Scale: Please input a value from 0-4. (0 = no chance of dozing, 4 = high chance of dozing off)
A M N O P. Q. R S T
Day & Date Sitting & Reading Watching TV Sitting in a public As a passenger in a car for an Lying down to rest in Sitting and Sitting quietly In a car or bus while stopped for a few
place hour without a break the afternoon talking to after lunch minutes in traffic
someone
Su

Please write legibly BY HAND (please DO NOT type, or print out your Excel sheet to turn in).
 Sleep Journal 2017 (continued)
Sleep Altering Factors and Dreams:
A. AA. AB.
Day & Date Circumstances / Events / Activities / Consumption and the time of day the sleep altering Number of Dreams Recalled Per Night (mark N for nightmares or anxiety
factor occurred dreams, L for lucid dreams)

Tu

W
Th
F

Sa
Su

Please write legibly BY HAND (please DO NOT type, or print out your Excel sheet to turn in).