Patient’s Name: ___________________________________________ Please Print
INSTRUCTIONS: Complete these logs as instructed using the directions provided below. Complete the logs in the morning and the evening. Do not complete the logs during the night. Write additional comments on the back. Bring these logs with you for your appointment or mail them to your physician.
1. Leave the times you are awake BLANK
2. SHADE, crosshatch or color the times you sleep
3. ARROW DOWN whenever you lie down to sleep
4. ARROW UPWARD when you awaken (include naps)
5. “M” – meals, “S” – snacks, and “D” – drinks with alcohol
6. Include notes below each week or on the back