Toad’s Weekly Assessment Template

Overview


Mood Score Key:

Sliding Hypomania = 1  ~ Hypomania = 2 ~  Mania = 3  ~  Baseline (My Normal) = 0

Sliding Depression = -1  ~  Depression = -2  ~  Severe Depression = -3 ~ M = Mixed State

Energy Score Key:

Low = -1  ~  Normal = 0  ~  High = 1

Irritation Score Key:

None = 0  ~  Mild = 1  ~  Moderate = 2  ~  Severe = 3

Anxiety Score Key:

None = 0  ~  Mild = 1  ~  Moderate = 2  ~  Severe = 3

Migraine Score Key:

None = 0  ~  Mild = 1  ~  Moderate = 2  ~  Severe = 3 ~ Extreme = 4 ~ Aura Present = A

Sleep Quality Score Key:

Bad = -1  ~  Normal = 0  ~  Great = 1


Special Notes for the Week

Menses Start Date: ~

Weigh-In at Med Clinic: ~


Sunday ~ Date

Mood: 0 ~ Energy: 0 ~ Irritation: 0 ~ Anxiety: 0 ~ Migraine: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity: ~ Exercise Time:

Meds Taken

Meals

Notes


Monday ~ Date

Mood: 0 ~ Energy: 0 ~ Irritation: 0 ~ Anxiety: 0 ~ Migraine: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity: ~ Exercise Time:

Meds Taken

Meals

Notes


Tuesday ~ Date

Mood: 0 ~ Energy: 0 ~ Irritation: 0 ~ Anxiety: 0 ~ Migraine: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity: ~ Exercise Time:

Meds Taken

Meals

Notes


Wednesday ~ Date

Mood: 0 ~ Energy: 0 ~ Irritation: 0 ~ Anxiety: 0 ~ Migraine: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity: ~ Exercise Time:

Meds Taken

Meals

Notes


Thursday ~ Date

Mood: 0 ~ Energy: 0 ~ Irritation: 0 ~ Anxiety: 0 ~ Migraine: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity: ~ Exercise Time:

Meds Taken

Meals

Notes


Friday ~ Date

Mood: 0 ~ Energy: 0 ~ Irritation: 0 ~ Anxiety: 0 ~ Migraine: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity: ~ Exercise Time:

Meds Taken

Meals

Notes


Saturday ~ Date

Mood: 0 ~ Energy: 0 ~ Irritation: 0 ~ Anxiety: 0 ~ Migraine: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity: ~ Exercise Time:

Meds Taken

Meals

Notes


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