Tode’s Weekly Assessment Template

Overview


Mood Score Key:

Name Mood State

Score Intensity 0 – 10 (0 = None, 10 = Most Extreme)

Energy Score Key:

Score Intensity 0 – 10 (0 = None, 10 = Most Extreme)

Irritation Score Key:

Score Intensity 0 – 10 (0 = None, 10 = Most Extreme)

Anxiety Score Key:

Score Intensity 0 – 10 (0 = None, 10 = Most Extreme)

Pain Score Key:

Name Type of Pain

Score Intensity 0 – 10 (0 = None, 10 = Most Extreme)

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 ~ Pain: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity:

Exercise Time:

Meds Taken

Meals

Feeling

Notes


Monday ~ Date

Mood: 0 ~ Energy: 0 ~ Irritation: 0 ~ Anxiety: 0 ~ Pain: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity:

Exercise Time:

Meds Taken

Meals

Feeling

Notes


Tuesday ~ Date

Mood: 0 ~ Energy: 0 ~ Irritation: 0 ~ Anxiety: 0 ~ Pain: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity:

Exercise Time:

Meds Taken

Meals

Feeling

Notes


Wednesday ~ Date

Mood: 0 ~ Energy: 0 ~ Irritation: 0 ~ Anxiety: 0 ~ Pain: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity:

Exercise Time:

Meds Taken

Meals

Feeling

Notes


Thursday ~ Date

Mood: 0 ~ Energy: 0 ~ Irritation: 0 ~ Anxiety: 0 ~ Pain: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity:

Exercise Time:

Meds Taken

Meals

Feeling

Notes


Friday ~ Date

Mood: 0 ~ Energy: 0 ~ Irritation: 0 ~ Anxiety: 0 ~ Pain: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity:

Exercise Time:

Meds Taken

Meals

Feeling

Notes


Saturday ~ Date

Mood: 0 ~ Energy: 0 ~ Irritation: 0 ~ Anxiety: 0 ~ Pain: 0

Hours of Sleep:

Sleep Quality: 0

Exercise Activity:

Exercise Time:

Meds Taken

Meals

Feeling

Notes



Last Updated: 01/14/2021

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