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  1. Surveys
  2. 2008
  3. September
  4. D
  5. Daily Tracking
0%
 
 
* Date of Survey (default - today):
 
 
How good did you feel today?

1 = good
2 = pretty good
3 = average
4 = worse than usual
5 = bad
1 2 3 4 5
* Day's Rating
 
On a scale from 1 to 5, how would you rate your symptoms today?

1 = no noticeable occurrence
2 = some occurrence
3 = significant occurrence, did not impact my ability to function
4 = significant enough to impact my ability to function
5 = constant and overpowering

N/A = Let's remove this symptom

1 2 3 4 5
* Depression
* Agitation
 
Depression Specifics:
1 2 3 4 5
Overwhelmed
Exhaustion
Sadness/Hopelessness
Boredom/ Lack of Will
 
Agitation Specifics:
1 2 3 4 5
Overwhelmed
Anxious
Rocking/ Pacing
Sleeplessness
Racing/ Obsessive Thoughts
 
 
Yes No Questions:
Y N -
* *Brain*______Could you concentrate on tasks?
* ____________Could you think creatively?
* ____________Could you complete cognitively challenging activities?
* *Sleep*______Did you pass out on the couch?
*Plans*______Did you have a plan for today?
____________Do you have a plan for tomorrow?
*Exercise*____Did you work out?
 
 
Sleep:

(0 = 12am or noon, 0.5 = 12:30, etc.)
8 8.5 9 9.5 10 10.5 11 11.5 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5
Went to bed:
Got up:
Hours slept:
Hours Napped:
 
 
 
Amount:
   mg
Time Taken:
   am/pm
 
 
 
* Detail any changes in medicine (dose OR timing) beginning today (or enter "none")
   
* Summary of days activities
   
* Tomorrow I plan on
   
Suggestions for the survey
   
 
Please contact [email protected] if you have any questions regarding this survey.
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