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My Sleep
Sleep Prescription
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Add Sleep
My Sleep
Prescription
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Date (MM/DD/YYYY) :
Did you nap or doze yesterday?
Yes
No
In total, how long did you nap or doze?
0 Minutes
05 Minutes
10 Minutes
20 Minutes
30 Minutes
40 Minutes
50 Minutes
1 Hour
1 Hour 10 minutes
1 Hour 20 minutes
1 Hour 30 minutes
1 Hour 40 minutes
1 Hour 50 minutes
2 Hours
2 Hours 10 minutes
2 Hours 20 minutes
2 Hours 30 minutes
2 Hours 40 minutes
2 Hours 50 minutes
3 Hours
3 Hours 10 minutes
3 Hours 20 minutes
3 Hours 30 minutes
3 Hours 40 minutes
3 Hours 50 minutes
4 Hours
4 Hours 10 minutes
4 Hours 20 minutes
4 Hours 30 minutes
4 Hours 40 minutes
4 Hours 50 minutes
5 Hours
What time did you get into bed yesterday?
What time did you try to go to sleep?
How long did it take you to fall asleep?
0 Minutes
05 Minutes
10 Minutes
20 Minutes
30 Minutes
40 Minutes
50 Minutes
1 Hour
1 Hour 10 minutes
1 Hour 20 minutes
1 Hour 30 minutes
1 Hour 40 minutes
1 Hour 50 minutes
2 Hours
2 Hours 10 minutes
2 Hours 20 minutes
2 Hours 30 minutes
2 Hours 40 minutes
2 Hours 50 minutes
3 Hours
3 Hours 10 minutes
3 Hours 20 minutes
3 Hours 30 minutes
3 Hours 40 minutes
3 Hours 50 minutes
4 Hours
Did you wake up during the night?
Yes
No
How many times did you wake up during the night?
0
1
2
3
4
5
6
7
8
9
In total, how long did these awakenings last?
0 Minutes
05 Minutes
10 Minutes
20 Minutes
30 Minutes
40 Minutes
50 Minutes
1 Hour
1 Hour 10 minutes
1 Hour 20 minutes
1 Hour 30 minutes
1 Hour 40 minutes
1 Hour 50 minutes
2 Hours
2 Hours 10 minutes
2 Hours 20 minutes
2 Hours 30 minutes
2 Hours 40 minutes
2 Hours 50 minutes
3 Hours
3 Hours 10 minutes
3 Hours 20 minutes
3 Hours 30 minutes
3 Hours 40 minutes
3 Hours 50 minutes
4 Hours
What time was your final awakening?
What time did you get out of bed for the day?
Did you wake up earlier than desired?
0 Minutes
05 Minutes
10 Minutes
20 Minutes
30 Minutes
40 Minutes
50 Minutes
1 Hour
1 Hour 10 minutes
1 Hour 20 minutes
1 Hour 30 minutes
1 Hour 40 minutes
1 Hour 50 minutes
2 Hours
2 Hours 10 minutes
2 Hours 20 minutes
2 Hours 30 minutes
2 Hours 40 minutes
2 Hours 50 minutes
3 Hours
3 Hours 10 minutes
3 Hours 20 minutes
3 Hours 30 minutes
3 Hours 40 minutes
3 Hours 50 minutes
4 Hours
4 Hours 10 minutes
4 Hours 20 minutes
4 Hours 30 minutes
4 Hours 40 minutes
4 Hours 50 minutes
5 Hours
How would you rate your sleep quality?
Very Poor
Poor
Fair
Good
Very Good
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