My Weekly Sleep Chart - Slade Pharmacy

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My Weekly Sleep Chart
/
/
Date
Quality
Time
Drowsiness
Irritability
Hours
of sleep
taken
during
level
of sleep
(good,
to fall
the day
during
fair, poor)
asleep
(circle)
the day*
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
Present this chart to your doctor on your next visit.
* 1 = None, 2 = Some, 3 = Moderate, 4 = Fairly high, 5 = High

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