2 Pages
English
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Agenda du sommeil - version anglaise

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2 Pages
English

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Language English

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Your sleep diary
Start filling out the 1stline D1 with your doctor
Last name:……………………
First name: …………………
Date: ….. / ……
../…… ..
M.S. took ½ ZOLPIDEM, went to bed at 7.30 p.m., fell asleep at 9 p.m. after watching TV, slept until 7 a.m., with sleep interrupted by waking between midnight and 1 a.m. – M.S. went back to bed for a nap at 1.30 p.m. and slept from 3 to 4 p.m. and then got up. The quality of sleep and wellness were poor.
Sleep-inducing medication
Name of medication……………… …………………………………………… …………………………………………
..
. ....
Write down what you have taken each night to help you sleep in the “medication” column
Time spent in bed or sleeping (night, daytime nap)
Mark with an “X”: - the time you went to bed - the time you got up
Show the time spent asleep by shading the box:
Quality of sleep and wellness during the day
Note the quality of sleep and wellness during the day using: G poor= good P = VG = very good VP = very poor
..