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Use this sleep diary to make an accurate assessment of how much you sleep and

other factors associated with your sleep. This will help you to identify patterns and
areas for improving sleep hygiene. Also, many people who struggle with sleep
sleep diary difficulties make negative assumptions about their sleep (e.g. “I never sleep more than
5 hours a night”) and this worksheet can help you to check if this is really the case.
http://www.cci.health.wa.gov.au regarding the information from this website before making use of such information.
See website www.cci.health.wa.gov.au for more handouts and resources.
Pre-sleep information Bed/sleep pattern
Day/Date Naps (what Caffeine, Medication Pre-bed Day fatigue Tension in In-bed Lights out Time to fall Waking time Woke up? Hours slept Rest score
time & how alcohol, nico- (day total & activity level (0-5, 5 bed (0-5, 5 activities (time) asleep (number of (0-5, 5
long?) tine? (day before bed) (what did most tired) most tense) (minutes) times, how most
total & 4 hrs you do?) long) rested).
before bed) Day mood
(0-5, 5 Measure
most de- this after at
pressed) least 40
min awake
Example: 2pm, 40 2 coffees, 1 Nil. watched TV 3 - felt a bit 4 - felt very Read for 1 10:30pm 40 min 5:10am Once at 6 hrs 40 3 - felt
minutes beer, nothing after dinner, tired today tense when I hour 2am, back min somewhat
after 4pm 3 hours went to bed to sleep rested when
2 - not really after 20 I woke up
down minutes

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This document is for information purposes only. Please refer to the full disclaimer and copyright statement available at http://www.cci.health.wa.gov.au regarding the information from this website before making use of such information.
See website www.cci.health.wa.gov.au for more handouts and resources.