Behavioral and Mental Health Research "Feeling Form"
Today's date
-
Month
-
Day
Year
Date
How was your sleep last night?
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How are you feeling today?
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
What's one thing you're grateful for right now?
What are you looking forward to today?
Do you feel any of the following?
Feeling down depressed or hopeless
Feeling bad about yourself or that you are failure or have let yourself or your family down
Trouble concentrating on things, such as working, reading the newspaper or watching television
Thoughts that you would be better off dead or of hurting yourself in some way
Moving or speaking so slowly that other people could have noticed, or the opposite – being so fidgety or restless that you have been moving around a lot more than usual
None
Anything else you want to add?
Email-Optional
example@example.com
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