Sleep Profiler Sleep Diary

Your clinician has requested that you complete a Sleep Profiler Study. Sleep Profiler is worn on your forehead and provides a detailed assessment of how quickly you fall asleep, how deeply you sleep, and how often and for how long you are awake during the night.

Sleep Profiler is easy to use. The key to a successful study is proper cleaning of your forehead and affixing the three sensors. Once Sleep Profiler is properly affixed, it will remain in place throughout the night. The Sleep Profiler 7-minute instructional video will help you prepare for your study. Voice messages are delivered by the Sleep Profiler to help confirm that it is properly affixed. Complete the Sleep Diary on each morning after wearing the Sleep Profiler.

The Sleep Profiler study will be carefully reviewed and a report will be generated to summarize the findings. This information will be used by your clinician when reviewing the Sleep Profiler results.

Please submit each night promptly. Complete this diary as soon as you can after each night of sleep — ideally the same morning, while details are still fresh in your memory. The more detail you provide, the better your report. You can submit Night 1, Night 2, and Night 3 separately; you do not need to wait until all three nights are complete.

Patient Information Patient name Date of birth Phone number Email (optional, for a copy)

Night 1 Date study started: Did you take a prescription medication to help you fall or stay asleep?

Yes No

How many alcoholic beverages did you consume within 4 hours before bedtime? (Beer, glass of wine, mixed drink) How many caffeinated beverages did you consume within 4 hours before bedtime? (Coffee, soda, energy drink) What time did you turn the lights off and begin trying to fall asleep?

How long do you think it took you to fall asleep? DO NOT look at the clock.

How many times do you think you woke up between the time you first fell asleep and your final awakening? What was the total time you think you were awake after you initially fell asleep until you ended your night of sleep? DO NOT look at the clock. What time did you turn the device off for your final awakening that ended your night of sleep?

What time did you get out of bed with no further attempt at sleeping?

Approximately how long did you sleep last night? DO NOT look at the clock.

When you wore the Sleep Profiler device, was it turned ON the entire time you were asleep?

Yes No

NOTES:

Submit Night 1 now while it is still fresh in your memory — the more detail you provide, the better your report.

Night 2 Date: Did you take a prescription medication to help you fall or stay asleep?

Yes No

How long do you think it took you to fall asleep? DO NOT look at the clock.

What time did you get out of bed with no further attempt at sleeping?

Approximately how long did you sleep last night? DO NOT look at the clock.

When you wore the Sleep Profiler device, was it turned ON the entire time you were asleep?

Yes No

NOTES:

Submit Night 2 now while it is still fresh in your memory — the more detail you provide, the better your report.

Night 3 Date: Did you take a prescription medication to help you fall or stay asleep?

Yes No

How long do you think it took you to fall asleep? DO NOT look at the clock.

What time did you get out of bed with no further attempt at sleeping?

Approximately how long did you sleep last night? DO NOT look at the clock.

When you wore the Sleep Profiler device, was it turned ON the entire time you were asleep?

Yes No

NOTES:

Submit Night 3 now while it is still fresh in your memory — the more detail you provide, the better your report.

Clinical Assessment of Sleep Quality