Daily record of severity of problems

Please print and use as many sheets as you need for at least two FULL months of ratings.
Name or initials:																	Month/year:
Each evening note the degree to which you experienced each of the problems listed below. Put an "x" in the box which corresponds to the severity: 1 - not at all, 2 - minimal, 3 - mild, 4 - moderate, 5 - severe, 6 - extreme.
Enter day (Monday = "M", Thursday = "R", etc) >
Note spotting by entering "S" >
Note menses by entering "M" >
Begin rating on correct calendar day >		1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	21	22	23	24	25	26	27	28	29	30	31
1. Felt depressed, sad, "down", or "blue" or felt hopeless; or felt worthless or guilty	6
	5
	4
	3
	2
	1
2. Felt anxious, tense, "keyed up" or "on edge"	6
	5
	4
	3
	2
	1
3. Had mood swings (ie, suddenly feeling sad or tearful) or was sensitive to rejection or feelings were easily hurt	6
	5
	4
	3
	2
	1
4. Felt angry, or irritable	6
	5
	4
	3
	2
	1
5. Had less interest in usual activities (work, school, friends, hobbies)	6
	5
	4
	3
	2
	1
6. Had difficulty concentrating	6
	5
	4
	3
	2
	1
7. Felt lethargic, tired, or fatigued; or had lack of energy	6
	5
	4
	3
	2
	1
8. Had increased appetite or overate; or had cravings for specific foods	6
	5
	4
	3
	2
	1
9. Slept more, took naps, found it hard to get up when intended; or had trouble getting to sleep or staying asleep	6
	5
	4
	3
	2
	1
10. Felt overwhelmed or unable to cope; or felt out of control	6
	5
	4
	3
	2
	1
11. Had breast tenderness, breast swelling, bloated sensation, weight gain, headache, joint or muscle pain, or other physical symptoms	6
	5
	4
	3
	2
	1
At work, school, home, or in daily routine, at least one of the problems noted above caused reduction of productivity or inefficiency	6
	5
	4
	3
	2
	1
At least one of the problems noted above caused avoidance of or less participation in hobbies or social activities	6
	5
	4
	3
	2
	1
At least one of the problems noted above interfered with relationships with others	6
	5
	4
	3
	2
	1

Graphic 86743 Version 2.0

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Daily record of severity of problems