Name

Task 1. Sleep disruption list

For the statements below, indicate whether and how often per week you experience the situations described.
Unable to fall asleep at night
Waking up at night frequently
Unable to fall asleep at night and waking up frequently during the night
Being overtired or having low energy
Daytime dozing
Experiencing concentration and memory problems during the day
Experiencing mood problems during the day

Task 2. Dozel score list

For each activity below, indicate how likely you are to nod off during the activity by giving one of the following socres: 0. Never likely to doze off 1. Little chance of dozing off 2. Reasonable chance of dozing off 3. High probability of dozing off.
Sitting and reading
Enter a number less than or equal to 3.
Watching TV
Enter a number less than or equal to 3.
Sitting in a public place (theater)
Enter a number less than or equal to 3.
One hour of driving without a fellow passenger
Enter a number less than or equal to 3.
In the afternoon
Enter a number less than or equal to 3.
Sitting and talking with someone
Enter a number less than or equal to 3.
Sitting quietly after lunch
Enter a number less than or equal to 3.
Sitting in car at traffic light
Enter a number less than or equal to 3.

Task 3. Sleep diary

Keep the following sleep diary for one week:
Time of going to bed
Enter in the morning what time you went to bed each night
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Time for falling asleep
In the morning, fill in how long you were in bed before you fell asleep
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
How often/how long awake
In the morning, fill in how often and how long you were awake during the night
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Thoughts while awake
In the morning, fill in what your thoughts were while awake
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Activities while awake
In the morning, fill in what your activities were while awake
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Times of rising
Enter in the morning what time you got up each day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Total sleep duration
Enter in the morning what the total sleep duration was
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Number/duration of daytime naps
At night, fill in how many naps you took during the day and how long the naps lasted
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Occupations/circumstances
In the evening, fill in what your activities and relevant circumstances were during the day (briefly)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Thoughts/concerns
In the evening, fill in what your main thoughts and/or concerns were during the day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Caffeine/coffee/tea
In the evening, fill in how much coffee, caffeine and tea you drank during the day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Alcohol/nicotine/drugs
Fill in at night if and how much alcohol/nicotine/drug you used during the day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Self-care
In the evening, fill in what you did during the day in terms of self-care
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Medicine
In the evening, fill in which medications you took during the day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Fatigue
Fill in at night how tired you were during the day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
Irritability
Fill in at night if and how irritable you were during the day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 

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