Sleep Sheet – Weekly

Download the printable PDF version…

Name: _______________________________________

 

Week # ___________ Mon Tue Wed Thu Fri Sat Sun
Fill in Date:               
What sleep prep ritual, meds
or induction procedure did
you use?
               
What time did you go to bed?

“Lights out” time for sleep?

A

B

             
About how long did it take you to fall asleep (rounded to ¼ hour)? C              
How many times did you wake up during the night? D              
About how long were you awake during the night (total time of awakenings rounded to ¼ hour)?  E              
Final wake up time?
  
When did you get out of bed?
F

G

             
What was your total
Time in Bed?
[B until G]
H              
What was your
Total Sleep Time?
[B until G – (C + E)]
I              
How refreshing was your sleep?

Poor    Fair    Good    Excellent
1   2   3   4   5   6   7   8   9   10

               
Sleep Efficiency (SE)

SE = I (TST) x 100 =
        H (TIB)

  _____% _____% _____% _____% _____% _____% _____%



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