In an effort to provide you with the best treatment options for your sleeping issue, your healthcare provider will need to know details about your specific sleep problem. The Healthy Sleeping Sleep Diary is a handy printout that will help you keep track of your daily sleep activities. To use the Healthy Sleeping Sleep Diary, print the two-page chart using your Internet's browser. For the next seven days, record your experiences in the spaces provided. Bring your completed Sleep Diary with you the next time you see your healthcare provider, so he or she can help determine the most appropriate treatment strategy for your particular sleep problem.

SLEEP DIARY

ANSWER IN THE MORNING AFTER WAKING FOR THE DAY
	At what time did you first go to bed last night?	Approximately how long did it take you to fall asleep?	About how many times, if any, did you awaken during the night?	Overall, about how many hours did you sleep?	At what time did you wake up (for the last time) this morning?	In general, how did you feel when you woke up?
DAY 1						Very refreshed Somewhat refreshed Fatigued
DAY 2						Very refreshed Somewhat refreshed Fatigued
DAY 3						Very refreshed Somewhat refreshed Fatigued
DAY 4						Very refreshed Somewhat refreshed Fatigued
DAY 5						Very refreshed Somewhat refreshed Fatigued
DAY 6						Very refreshed Somewhat refreshed Fatigued
DAY 7						Very refreshed Somewhat refreshed Fatigued

ANSWER AT BEDTIME JUST BEFORE YOU GO TO SLEEP
	How much time, if any, did you spend napping during the day?	Did you consume any of these substances during the day?	On a scale of one to five, how would you rate your overall mood and overall functioning during the day?
DAY 1		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 - Positive & energetic 4 3 2 1 - Depressed & lethargic
DAY 2		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 - Positive & energetic 4 3 2 1 - Depressed & lethargic
DAY 3		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 - Positive & energetic 4 3 2 1 - Depressed & lethargic
DAY 4		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 - Positive & energetic 4 3 2 1 - Depressed & lethargic
DAY 5		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 - Positive & energetic 4 3 2 1 - Depressed & lethargic
DAY 6		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 - Positive & energetic 4 3 2 1 - Depressed & lethargic
DAY 7		Caffeine (within 6 hours of bedtime) Alcohol (within 1 hour of bedtime) Medication (type:_______________)	5 - Positive & energetic 4 3 2 1 - Depressed & lethargic

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