Fillable sleep diary Pre-sleep information Bed/sleep pattern (Services Australia)

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sleep diary Pre-sleep information Bed/sleep pattern (Services Australia)

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The sleep diary Pre-sleep information Bed/sleep pattern (Services Australia) form is 1 page long and contains:

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Country of origin: AUSTRALIA
File type: PDF

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Services Australia, (previously DHS - Department of Human Services) is responsible for delivering services relating to health and welfare of Australian citizens. It processes payment of child support other services.

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This document is for information purposes only. Please refer to the full disclaimer and copyright statement available at
http://www.cci.health.wa.gov.au regarding the information from this website before making use of such information.
See website www.cci.health.wa.gov.au for more handouts and resources.
sleep diary
Use this sleep diary to make an accurate assessment of how much you sleep and
other factors associated with your sleep. This will help you to identify patterns and
areas for improving sleep hygiene. Also, many people who struggle with sleep
difficulties make negative assumptions about their sleep (e.g. “I never sleep more than
5 hours a night”) and this worksheet can help you to check if this is really the case.
Pre-sleep information Bed/sleep pattern
Day/Date Naps (what
time & how
long?)
Caffeine,
alcohol, nico-
tine? (day
total & 4 hrs
before bed)
Medication
(day total &
before bed)
Pre-bed
activity
(what did
you do?)
Day fatigue
level (0-5, 5
most tired)
Tension in
bed (0-5, 5
most tense)
In-bed
activities
Lights out
(time)
Time to fall
asleep
(minutes)
Waking
time
Hours slept Woke up?
(number of
times, how
long)
Rest score
(0-5, 5
most rest-
ed)
Example: 2pm, 40
minutes
2 coffees, 1
beer, nothing
after 4pm
Nil. watched TV
after dinner,
3 hours
3 - felt a bit
tired today
4 - felt very
tense when I
went to bed
Read for 1
hour
10:30pm 40 min 5:10am 6 hrs 40
min
Once at
2am, back
to sleep
after 20
minutes
3 - felt
somewhat
rested when
I woke up
C
entre for
C
linical
I
nterventions
•Psychotherapy•Research•Training
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sleep diary Pre-sleep information Bedsleep pattern (Services Australia)

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Completed 2 November 2020

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