Date _______________ Complete after awakening: Time you went to bed _______________ Time you fell asleep _______________ Time you woke up _______________ Number of times awakened during the night _______________ Amount of time awake during the night _______________ Total Nighttime Sleep _______________ Comments on quality of night’s sleep: ____________________________________________________________ Did you feel groggy after getting up in the morning? Yes _____ If yes, for how long? _______________ Complete at the end of the day: Naps: Time fell asleep _______________ Time awoke _______________ Total Nap Time _______________ Comments on quality of naps: ____________________________________________________________ Using the Stanford Sleepiness scale below, note your alertness during the day. 1. 2. 3. 4. 5. 6. 7. Feeling active, vital, alert, wide awake Functioning at a high level, not at peak Relaxed, not full alertness, responsive A little foggy, not at peak, let down Fogginess, losing interest, slowed down Sleepiness, prefer to by lying down Almost in a reverie, hard to stay awake
6 AM 8AM 10 AM NOON 2 PM 4 PM 6 PM 8 PM 10 PM MDNT
No _____
How was your overall sleepiness/alertness today (1-7)? _______________ Other comments on mental and physical: ____________________________________________________________ ____________________________________________________________ Complete after awakening (using back of this page): 1. 2. 3. Do you remember any of your dreams? If so, write down every detail you can remember about the dream. Explain any latent content (relationship to deep wishes and goals) in the above dream. Explain any manifest content (relationship to events occurring in daily life) in the above dream.
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