Cambridge Health

Alliance

Harvard Medical
School

Sleep Log
Name

MRN

Instructions
1. Be sure to write your name on the sheet.
2. Block in each 1/2 hour you slept. Dont block in any 1/2 hour periods
during which you were awake.
3. Use a bold diagonal line for those periods when you were sleepy.
4. Add up the time you spent sleeping and enter it in the far right column.
5. Use the below symbols or letters above the time of activity or experience.
= In bed

= Out of bed

Example:
Date

C = caffeinated coffee/tea/soda

A = alcohol

E
Noon

1 PM

2 PM

Awake

Sleepy
Asleep

E =Exercise

P =Pain

S = sleep medicine

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

3 PM

8/12/01

Date

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

8.5

Date (day 1)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

Date (day 2)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

Date (day 3)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

Date (day 4)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

Date (day 5)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

Date (day 6)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

Date (day 7)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

Date (day 8)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

Date (day 9)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

Date (day 10)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

Date (day 11)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

Date (day 12)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

Date (day 13)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total

Date (day 14)

Noon

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

8 PM

9 PM

10 PM

11 PM

12 AM

1 AM

2 AM

3 AM

4 AM

5 AM

6 AM

7 AM

8 AM

9 AM

10 AM

11 AM

Total