7926 Preston Hwy. Suite 200
Louisville, KY 40219
Tel: (502) 964-2440
Fax: (866) 845-0491
www.KentuckySleep.com
Patient Name:
SLEEP LOG
DAY / MORNING / AFTERNOON / EVENINGDay 1 / Wake Time: / Nap Time: / Bed Time:
Day 2 / Wake Time: / Nap Time: / Bed Time:
Day 3 / Wake Time: / Nap Time: / Bed Time:
Day 4 / Wake Time: / Nap Time: / Bed Time:
Day 5 / Wake Time: / Nap Time: / Bed Time:
Day 6 / Wake Time: / Nap Time: / Bed Time:
Day 7 / Wake Time: / Nap Time: / Bed Time:
Please make any comments about each day below:
Day 1Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
BED-PARTNER OR PERSON OBSERVING PATIENT SLEEP QUESTIONNAIRE
Name of person filling out form:
I have observed this person’s sleep: Never Once or twice Often Every night
Check any of the following Ibehaviors that you have observed this person doing while asleep.
Light snoring Loud snoring Occasional Loud snorts
Choking Pauses in breathing Twitching or kicking of legs
Grinding Teeth Sleepwalking Twitching or Jerking of arms in sleep
Bed wetting Biting tongue Getting out of bed but not awake
Crying out Sitting up in bed not awake Awakening with pain
Becoming very rigid and or shaking
Apparently sleeping if he/she behaves otherwise
Other:
Please describe the sleep behaviors checked in more detail. Include a description of the activity, the time during the night when it occurs, frequency during the night and whether it occurs every night.
Has this person ever fallen asleep during normal daytime activities or in dangerous Situations?
YES NO
If YES please explain