Sleep Sheet – Nightly

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SLEEP EFFICIENCY SHEET
Please complete upon waking for accurate recall.


Name:_____________________________   Day: ______  Date: _______


A.  What time did you go to bed last night?

B.  When was “lights out” and readiness for sleep?

C.  About how long did it take you to first fall asleep?

[estimate and circle:  (¼)  (½)  (¾)  (1)  (1¼)  (1½)  (1¾)  (2)  (    ) hours]

D.  How many times did you wake up during the night?

[ total # awakenings:  ( 1 )  ( 2 )  ( 3 )  ( 4 )  ( 5 )  ( 6 )  (    ) times ]

E.  After initial sleep, about how long were you awake last night?

[estimate total time awake: (¼)  (½)  (¾)  ( 1 )  (1¼)  (1½)  (1¾)  ( 2 )  (    ) hours]

F.  What was your final wake up time?

G.  What time did you get out of bed?

H.  What was your total Time in Bed (B until G)?

I.  What was your Total Sleep Time [B until G – (C +E)]?

J.  What sleep preparation, ritual, induction or meds did you use?

K.  How would you rate the refreshing quality of your sleep last night?
(please circle a number below)

Poor                        Fair                     Good                   Excellent

1          2          3          4          5          6          7          8          9         10


Sleep Efficiency = (I) Total Sleep Time (TST) /(H) Time in Bed (TIB)  x 100 = _____% SE


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