Exercise /Medication Other Comments

Date (enter amounts, note dose changes) Energy/Mood Sleep

symptoms Alcohol =
Exercise How med 1 med 2 med 3 med 4 (can use two check marks: check one, or
type long enter 0-3 worst and best for each day) for instance: for instance:
L P K A hours
A R L B Agitation/
Walk M M O O I depressed nl
Swim I I Z N L 0=none anxiety/ “up”
(circle Run N C A O I 1=mild memory
for problems, significant events that might affect mood — interactions,

impaired
impaired

impaired

impaired
U T C P F

increased sleep
normal
2=moderate

cannot

cannot
Bike

mood

(naps)
work

work
T A I Y

not

not

normal sleep
menses) Etc. E L N 3=severe hallucinations, successes, disappointments, anniversaries, illness, losses,
paranoid ideas, etc.

insomnia
S

++ ++ etc.
300 mg 60 mg 1 mg 2 mg anx. irrit. +
++ + + ++
+
.1 mg
_____ __ 1 1 2 0 2 2 2 8 = Pych with Amy F. and Amy A.; Running out of med options; Tony
1 WED ------------------------

2 THR
_____ __ 1 1 2 0 2 2 - 7 - ------------------------ First day working at Allegheny Conference, went well

WALK __ 1 1 2 0 1 2 - 8 - Blood Work; Work at A.C.; Confusion about bus rides

3 FRI ------------------------

4 SAT
_____ __ 1 1 2 1 1 1 3 6 1 ------------------------ Drove to Tony’s; Ally is sick  Just hung out, watched tv

_____ __ 1 1 2 1 3 2 3 5 2 CRYING/CUTTING Tony might be having online sexual affair; I trust no one, nothing
5 SUN

_____ __ 1 1 2 1 3 3 2 6 2 CRYING Tony came to visit; Had long talk; He denies it; Still heartbroken
6 MON

7 TUE
ALL 45 1 1 2 1 2 2 - 6 1 ------------------------ Work at A.C.; hard time with the data; watched Hoffa

WALK 20 1 1 2 1 3 3 - 7 1 CRYING Hung out w/ guys at work; hate male animals; long talk w/ Tony
8 WED

WALK 20 1 1 2 1 3 2 - 5 3 CRYING Boring day at A.C.; Can’t sit still; restless; Don’t like Abilify
9 THR

10 FRI

11 SAT

12 SUN

13 MON
14 TUE
15 WED
16 THR
17 FRI
18 SAT
19 SUN
20 MON
21 TUE
22 WED
23 THR
24 FRI
25 SAT
26 SUN
27 MON
28 TUE
29 WED
30 THR
weight = 109 :THIGH– 20 WAIST– 24 : HIPS– 34.5