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TODAY'S DATE              
1. Last night, I took sleep medication. (yes or no)              
2. What time did you go to bed last night?              
3. After turning the lights off, how long did it take you to fall asleep?              
4. How long were you awake during the night?              
5. What time did you wake up this morning? (your last awakening in the morning)              
6. Overall, my sleep last night was___ :
1=very restless 2=restless 3=average quality 4=sound 5=very sound