General Instructions:

Please fill out your name and date of birth on each mood chart page. Each page is meant to chart one month at a time. Begin on the appropriate day of the month and continue charting until the end of the month. For example, if you begin the chart on May 15th, continue charting until the end of May and begin June on a separate page. However, if you begin your chart at the end of the month, for example May 27th, write in those last days of the
month in the blank spaces before the first of the month of June and continue charting until the end of the next month, in this case June.

Treatments:

For each day, record the total number of tablets of each medication that you have taken.Draw a line through the box to indicate if the medication was not taken that dayIf you are taking a medication PRN (as needed, indicate this next to the name of the medication and enter the dosage of the prescription. In the case of PRN medication, mark the amount of tablets taken that day in the appropriate blocks.

Major Life Events:

In this column note any significant event that happened on that day. Include any event that you feel contributed to your mood state on that day or may have precipitated a future episode. Include suicide attempts, hospitalization, and psychotic symptoms.

Menses:

For women, indicate days on which you had your period by circling the dates.

Mood Ratings:

There are three categories of mood ratings: Depressed, Elevated, or WNL (within normal limits). For each day, mark an “X” in the block that appropriately describes your mood at its best and worst for that day (you will therefore possibly have two marks for each day). If symptoms of both mood elevation and depression are present in any given day indicate the severity of each. Also, indicate the presence of any psychotic symptoms
(hallucinations, delusions) on any day by marking an “X” in that column.

Drug Level:

If you are taking Lithium, Tegretol (Carbamazepine), or Depakote(Valproate) and have had a blood level done, mark the level on the day that your blood was drawn and use the chart to indicate the level. For Lithium, make the level with an “L”, for Tegretol use a “T”, and for Depakote use a “D”.

Weight:

Record your weight and the day on which you weighed yourself. You should weigh yourself on the same day each month (e.g., the 5th of each month).