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Date/D Time Time Dream # of How # of Energy Caffein
ay to Bed Awake s? hours did you Naps level e
(includ of feel today througho Intake
e sleep upon ut the
summa waking Day
ry if ?
yes)
1 2 3 4 5 6 7 8 9
Date/D Time Time Dream # of How # of Energy Caffein
ay to Bed Awake s? hours did you Naps level e
(includ of feel today througho Intake
e sleep upon ut the
summa waking Day
ry if ?
yes)
1 2 3 4 5 6 7 8 9
Date/D Time Time Dream # of How # of Energy Caffein
ay to Bed Awake s? hours did you Naps level e
(includ of feel today througho Intake
e sleep upon ut the
summa waking Day
ry if ?
yes)
1 2 3 4 5 6 7 8 9
Date/D Time Time Dream # of How # of Energy Caffein
ay to Bed Awake s? hours did you Naps level e
(includ of feel today througho Intake
e sleep upon ut the
summa waking Day
ry if ?
yes)
1. How many times did you wake up last night? ___________________
2. How good was your sleep last night? (Circle a # below)
Very poor 1 2 3 4 5 6 7 very good
3. How many dreams can you remember at least some part of? _______________
4. Were you the main character in each of your dreams? ____________________
5. Were your dreams in color? _______________________
6. Were your dreams related to things that had happened to you during the
previous day?
______________________________________________________________________________
7. Did you have any sensations other than vision (smell, taste, and so on) in
your dreams? _______
If so, list the sense experienced:
____________________________________________________
1 2 3 4 5 6 7 8 9
Date/D Time Time Dream # of How # of Energy Caffein
ay to Bed Awake s? hours did you Naps level e
(includ of feel today througho Intake
e sleep upon ut the
summa waking Day
ry if ?
yes)
1 2 3 4 5 6 7 8 9
Date/D Time Time Dream # of How # of Energy Caffein
ay to Bed Awake s? hours did you Naps level e
(includ of feel today througho Intake
e sleep upon ut the
summa waking Day
ry if ?
yes)
1 2 3 4 5 6 7 8 9
Date/D Time Time Dream # of How # of Energy Caffein
ay to Bed Awake s? hours did you Naps level e
(includ of feel today througho Intake
e sleep upon ut the
summa waking Day
ry if ?
yes)