SLEEP LOG

Name (Optional):
Course:
Year and Section:
Please check the appropriate box:
▢ I am a regular coffee drinker
▢ I do not drink coffee at all
Start Date: End Date:

WEEK 1
Day 1
Date:
Bedtime:
Wake time:

Please check the appropriate boxes:

Morning Coffee
▢ Yes, I drank coffee this morning (between 6:00 AM and 11:59 AM).
If yes please specify:
▢ Small cup (8 oz or less)
▢ Medium cup (8-12 oz)
▢ Large cup (more than 12 oz)
▢ No, I did not drank coffee this morning.

Afternoon Coffee
▢ Yes, I drank coffee this afternoon (between 12:00 PM and 5:59 PM).
If yes please specify:
▢ Small cup (8 oz or less)
▢ Medium cup (8-12 oz)
▢ Large cup (more than 12 oz)
▢ No, I did not drank coffee this afternoon.

Evening Coffee
▢ Yes, I drank coffee this evening (between 6:00 PM and 11:59 PM).
If yes please specify:
▢ Small cup (8 oz or less)
▢ Medium cup (8-12 oz)
▢ Large cup (more than 12 oz)
▢ No, I did not drank coffee this evening.

Late Night Coffee

▢ Yes, I drank coffee late at night (between 12:00 AM and 5:59 AM).
If yes please specify:
▢ Small cup (8 oz or less)
▢ Medium cup (8-12 oz)
▢ Large cup (more than 12 oz)
▢ No, I did not drank coffee late at night.

Morning Feelings
Rate your sleep quality on a scale of 1 to 10. (1 being poor, 10 being excellent).
▢1 ▢2 ▢3 ▢4 ▢5 ▢6 ▢7 ▢8 ▢9 ▢10

Sleep Quality
• How refreshed do you feel this morning? (1 being not refreshed at all, 10 being very refreshed).
▢1 ▢2 ▢3 ▢4 ▢5 ▢6 ▢7 ▢8 ▢9 ▢10
• Did you have any vivid dreams or nightmares?
▢ Yes ▢ No
• Number of awakenings during the night: Duration: hi

Additional Notes:
(Use this space to record any additional information about your sleep or the previous day that may be relevant, such as
unusual sleep disturbances or daytime sleepiness.)