Sleep and Ventilation Unit

Department of Respiratory Medicine

City General Hospital
Newcastle Road
Stoke-on-Trent
Staffordshire
ST4 6QG
Tel: 01782 552324

Ref: AE/

Date:

Name:

Address:

Dear

To help us understand your sleep problems we would like you to keep a sleep diary for the
next _____ days.

Using the options listed on the diary please report your daily activities and sleep experience
in the spaces provided.

The diary should be kept by the bedside and the relevant information charted before and
after bedtime each day. Behind the weekly log is a page for your comments, which you think
important.

An example has been set out for you to study overleaf.

If you have any queries please telephone the department on the above number.

IT IS IMPORTANT THAT YOU KEEP THIS DIARY FOR THE NEXT _____ DAYS

Yours sincerely

Ann Cooper Dr Martin Allen

Senior Polysomnographer Consultant Physician
READ THE OPTIONS BELOW, CHOSE WHICH APPLY TO YOU AND USE THE
RELEVANT LETTER TO RECORD THE INFORMATION IN YOUR DIARY.

Daytime/Evening Activities

A= Alcohol

E= Exercise

L= Lifestyle factor e.g. Jet lag, shift work

M= Medication

N= Naps

S= Stress e.g. Bad news, anxiety, work

U= Unwell e.g. flu, arthritis

O= Other you think important

Sleep Experience

C= Sleeping conditions e.g. uncomfortable bed, noise, temperature

D= Unpleasant dreams, nightmares

P= Pain

T= Toilet

W= Worry

Medications:
Please list all medications taken together with amounts:-

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________
 SLEEP DIARY

NAME:_________________________________

DATE OF BIRTH:________________________

Example 1 2 3 4 5 6 7
Day Monday

Date 1/01/01

Total sleep 4h

Bed Time 11.45pm

Estimated
time to fall
45mins
asleep

Awakenings x2
& Times 2am/3am

Final wake
6:30am
Time

Toilet during
2
night
Caffeine
13
drinks

Day/Eve
A S U
activities

Sleep
W T
experience

2
10am train
Naps-Time,
15mins
where, how
8pm Chair
long
at home
10mins

COMMENTS
1. ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

2. ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

3. ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

4. ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

5. ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

6. ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

7. ______________________________________________________________________________

______________________________________________________________________________

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