A Quiet Voice HomeA Quiet Voice Home

A Journal Template

Daily Journaling Home
Journal Template
Interpretation
Inner Thoughts
Resources
My Practice
Helping Resources
For Professionals
Search the Site
Home


Here's a sample journal page which includes various items you might want to track.  I included lots of detail to give you ideas.  You may decide to record all areas or only a few.  Decide how much to track based on what feels manageable to you and on your ultimate goals (e.g. understanding physical symptoms or emotional expression).

Download template for printing

Date:

________________________ Weather: Sunny | Cloudy | Partly Cloudy 
 Rain |Snow | Humid | Dry
  

M TU W TH F SA SU

Hot  | Cold  | Just Right

  

(Circle Day)

Other:_______________________________
Moods 
You might record your best sense of your overall mood for the day, or record the separate moods you experienced during the day.  Are you interested in the "emotional theme" for the day, or would you rather focus on how your mood shifts?

Happiness:

0 1 2 3 4 5 6 7 8 9 10

Anger:

0 1 2 3 4 5 6 7 8 9 10

  

0=none; 10=extreme

  

0=none; 10=extreme

Anxiety:

0 1 2 3 4 5 6 7 8 9 10

Depression:

0 1 2 3 4 5 6 7 8 9 10

  

0=none; 10=extreme

  

0=none; 10=extreme

Cognitive Symptoms

Concentration:

0 1 2 3 4 5 6 7 8 9 10

Forgetfulness:

0 1 2 3 4 5 6 7 8 9 10

  

bad

good

  

none

extreme

Decision Making
Ability:

0 1 2 3 4 5 6 7 8 9 10

Motivation:

0 1 2 3 4 5 6 7 8 9 10

bad

good

  

none

extreme

Physical Symptoms 
Check those that apply: mild severe
Headache: Severity: 1 2 3 4 5 6 7 8 9 10
Stomachache: Severity: 1 2 3 4 5 6 7 8 9 10
Other Pain:

Severity:

1 2 3 4 5 6 7 8 9 10
Menstruating? yes/no

Describe:

_________________________________
(Examples of other pain:  knee pain, shoulder pain, etc.)

Fatigue:

0 1 2 3 4 5 6 7 8 9 10

Aches and pains:

0 1 2 3 4 5 6 7 8 9 10

  

none

extreme

  

none

extreme

Daily Functioning
Functioning means the ability to perform everyday tasks such as working, going to school, bathing, dressing, cleaning and cooking.  A score of 0 means you are unable to function at all.   Examples:  You can't get out of bed, dress, or bathe.  A score of 10 means you feel no impairment in your functioning.
cannot
function

functioning perfectly

General Functioning:

0 1 2 3 4 5 6 7 8 9 10
Eating
Enter the time you ate, what you ate, whether you under-ate (U), over-ate (O), or ate an amount that felt right (R); what was happening at the time you were eating [e.g. you were eating with friends, arguing, watching TV], how you felt before you ate [e.g. sad, lonely, angry] and how you felt after eating [e.g. guilty, happy, upset], and add any notes or comments you want to make.  Tracking your eating like this may be particularly helpful for those with eating disorders, including compulsive eating--you may be able to discover events, feelings or thoughts that trigger a binge or lead you to not want to eat.
 
Meal Time What I Ate U/O/R What Was Happening Feelings Before Feelings After Notes
Breakfast:                     
Lunch:                       
Dinner:                     
Snack:                       
Snack:                     
Medications
Name Time Amount (mg)
     
     
     
     
     
     
Other Substances
Substance Time Amount
     
     
Exercise
Exercised?

yes / no

Activity For How Long? How was the workout?  Was it a good or bad session (felt more difficult or easier than usual)?
     
     
Sleep
Time I Went To Bed:   Notes:
Time I Got Up:  
Hours Slept:  
Restful Sleep? y / n
Nightmares? y / n

Woke often?

y / n

Activities (e.g. I went shopping, went to the movies, did spring cleaning, watched tv all evening, etc.)



Psychotherapy

Therapy?

yes / no

Notes:






Notes: [meaningful events, description of day, personal thoughts, family or other relationship interactions--this is your space to write what you wish]











Comments, questions, or suggestions?  Please, email me.

Daily Journaling Home | Journal Template | Interpretation | Inner Thoughts | Resources
Home | My Practice | Helping Resources | For Professionals | Search | About | Contact Me| Legal Notice and Disclaimer

Jonathan P. Levine, CSW
2300 West Ridge Rd.
Rochester, NY  14626
(585) 225-0330
jonathan@aquietvoice.com
Updated on 05/12/2000
2002, Jonathan P. Levine, CSW