Please answer questions A to S each day over the next two weeks. There should be three sheets of paper for answers to be written in boxes. The aim is to measure the pattern and quality of your sleep, and factors that may affect your sleep over the course of two weeks.
- Questions A to I relate to the night's sleep. Try to answer these soon after getting up each day when the details of the previous night are fresh in your mind.
- Questions J to S relate to to the day leading up to the night's sleep. Try to answer these at least an hour before you go to bed when the details are fresh in your mind.
A. What time did you wake up this morning?
B. What time did you go to bed last night?
C. About how long did it take to first fall asleep? (Record in minutes - for example, 70 mins.)
D. How many times did you wake up during the night (enough to be fully aware)?
E. How long did you sleep last night in total? (In hours and minutes - for example, 4 hr 30 mins.)
F. Did you take any sleeping tablets last night to help you sleep?
G. How generally well do you feel today? Record on a scale 1-4. 1 - not well at all. 2 - just OK. 3 - fine. 4 - very well.
H. How energetic do you feel today? Record on a scale 1-4. 1 - lethargic. 2 - slow but OK. 3 - fine. 4 - very energetic.
I. How enjoyable was your sleep last night? Record on a scale 1-4. 1 - not at all. 2 - just OK. 3 - fine. 4 - very good.
J. How many cups of caffeine drinks (tea, coffee, cola, etc) did you have before 5 pm?
K. How many cups of caffeine drinks (tea, coffee, cola, etc) did you have after 5 pm?
L. How many units of alcohol did you have before 5 pm? One unit of alcohol is about equal to: half a pint of ordinary strength beer/lager, or a small pub measure (25 ml) of spirits, or a standard pub measure (50 ml) of sherry or port, or a small glass of ordinary strength wine.
M. How many units of alcohol did you have after 5 pm?
N. How much moderate or vigorous physical activity/exercise did you do before 9 pm? (Record in minutes - for example, 40 mins.) Moderate physical activity/exercise includes brisk walking, jogging, dancing, swimming, heavy DIY, gardening, etc.
O. How much moderate or vigorous physical activity/exercise did you do after 9 pm?
P. Did you take any street drugs (cocaine, amfetamines, heroin, etc)? Yes/No. If yes, write down which one(s).
Q. Did you have any naps during the day or evening? Yes/No
R. If you did nap, how long in total where the naps? Record in minutes.
S. Fill in any other details that may be relevant. For example, if you were particularly stressed, anxious, depressed or ill.
|Original Author: Dr Tim Kenny||Current Version: Dr Tim Kenny|
|Last Checked: 25/05/2011||Document ID: 4450 Version: 38||© EMIS|
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