NAME & Social Security #

DAYS OF THE WEEK

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1.    I went to bed at: (Give clock time

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2.    I fell asleep at: (Give clock time)

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3.    It took me _____ minutes to fall asleep. (SSL)

4.    I woke up for the day at _____. (Give clock time)

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5.    I got out of the bed for the day at _____ (Clock time)

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6.    I spent _____ hrs. in bed last night.

7.    I woke up _____ times last night.

8.    Amount of time awake after first falling asleep (minutes)

9.    I took _____ naps yesterday. (Give #)

10.   My naps lasted for a total of _____ minutes. (Give total)

11.   I took naps at (list the clock times).

12.   Sleep Quality: 1. very poor 2. poor 3. OK 4. good 5. very good

13.   Sleep Quantity: 1. very inadequate 2. inadequate 3. about right 4. too much

14.   I had _____ cups of caffeinated coffee yesterday.

15.   I had _____ cans/bottles of caffeinated cola yesterday.

16.   I had _____ glasses of caffeinated tea yesterday.

17.   I had _____ bars of chocolate yesterday

18.   I smoked _____ cigarettes yesterday.

19.   Did you dream last night? (YES or NO)

         If you did dream, please comment at the bottom of this paper.

20.   Do you take meds to sleep? (YES or NO)

21.   What is/are the meds you use to sleep?

22.   List the meds you took yesterday.

Please list your age.

Height (inches)

Weight (pounds)