MONTH

____

____

____

____

____

____

____

____

____

__YEA

R___

____

____

____

_

HOUR

S OF N

IGHTTI

ME SL

EEP

NUMB

ER OF

MOOD

CHAN

GES

SEVERE

HIGH M

ODERA

TE

HIGH M

ODERA

TE

MIXED

STATE

(✔

) IF YE

S

MOOD

(0–

10)

ANXIE

TY SYM

PTOMS

(✔

) IF YE

S

LOW M

ODERA

TE

LOW M

ODERA

TE

MILD

MILD

SEVERE

Esse

ntiall

y inc

apac

itated

or H

OS

PIT

ALI

ZED

GREA

T diffi

culty

with

goal-

orien

ted ac

tivity

SOME

diffic

ulty w

ith go

al-ori

ented

activ

ity

More

energ

ized &

prod

uctiv

e; us

ual ro

utine

not a

ffecte

d muc

h

Usua

l routi

ne no

t affe

cted m

uch

Func

tionin

g with

SOME

effor

t

Func

tionin

g with

GREA

T effo

rt

Esse

ntiall

y inc

apac

itated

or H

OS

PIT

ALI

ZED

-10 • •

• • • •

• • • •

• • • •

0 • •

• • • •

• • • •

• • • •

•+10

Most

depre

ssed

ever

Balan

ced

Most

manic

ever

USED

ALCOH

OL/DR

UGS

(✔) IF

YES

12

34

56

78

910

1112

1314

1516

1718

1920

2122

2324

2526

2728

2930

31

STABLE

TO

TA

L

NU

MB

ER

O

F

PI

LL

S

TA

KE

N

PE

R

DA

YME

DICATI

ON/SU

PPLEM

ENT N

AME

DAILY DOSE

# OF P

ILLS

PER DA

Y

LIFE E

VENTS

23

45

67

89

1011

1213

1415

1617

1819

2021

2223

2425

2627

2829

3031

1

OTHER

SYMPTO

MS

23

45

67

89

1011

1213

1415

1617

1819

2021

2223

2425

2627

2829

3031

1

IM

PA

CT

(

-1

0=

MO

ST

N

EG

AT

IV

E;

10

=M

OS

T

PO

SIT

IV

E)

IN

TE

RF

ER

EN

CE

W

IT

H

LIF

E

(0

=L

EA

ST

;

10

=M

OS

T)

M A N I A D E P R E S S I O N

Depression and Bipolar Support Alliance730 N. Franklin Street, Suite 501, Chicago, Illinois 60610-7224 USAPhone: (800) 826-3632 or (312) 642-0049 Fax: (312) 642-7243W

eb site: www.DBSAlliance.org

Symptoms of mania/hypomania• Increased energy• Agitated or irritable m

oods• Inflated self-esteem

or grandiose feelings• Decreased need for sleep• M

ore talkative than usual, or pressure to keep talking

• Flight of ideas or racing thoughts• Easily distracted• Excessive involvem

ent in pleasurableactivities (spending sprees, sexual activity,foolish investm

ents or business ventures)

Symptoms of depression•

Decreased energy•

Sad, empty feelings

•Loss of interest or pleasure in usualactivities

•Inability to concentrate

•Significant weight loss or gain

•Change in sleep patterns, inability tosleep, or increased periods of sleep

•Feelings of worthlessness or inappropriate guilt

•Inability to m

ake decisions•

Recurring thoughts of death or suicide

5.

Record

mix

ed s

tate

sIf

you

have

sym

ptom

s of m

ania

and

depr

essio

n at

the s

ame t

ime (

am

ixed

state)

put

a ch

eck m

ark (

✔) i

n th

e app

ropr

iate d

ay’s

spac

e.

6.

Rate

your

ove

rall m

ood

Rate

your

moo

d fo

r the

day

and

write

a nu

mbe

r bas

ed o

n th

e moo

d sc

alebe

low.

-10 . .

. . . .

. . . .

. . . .

. . . .

. . . .

. 0 . . . .

. . . .

. . . .

. . . .

. . . .

. . . +1

0Mo

st de

press

ed ev

erBa

lance

dMo

st ma

nic (a

ctiva

ted) e

ver

7.

Record

the n

um

ber

of

mood c

hanges

Enter

the

appr

oxim

ate n

umbe

r of t

imes

you

r moo

d ch

ange

d du

ring

the

day.

8.

Record

anxie

ty s

ympto

ms

Plac

e a ch

eck m

ark (

✔) b

y the

day

s you

hav

e sym

ptom

s of a

nxiet

y, pa

nic,

or ex

cess

ive w

orry.

9. R

ecord

oth

er

sym

pto

ms,

both

phys

ical

and m

enta

l

List

any p

hysic

al or

men

tal sy

mpt

oms y

ou h

ave t

hat i

nter

fere w

ith yo

ur li

fe,su

ch as

loss

of a

ppeti

te, p

ain, n

ause

a, pa

rano

ia or

thou

ghts

of su

icide

.Ra

te th

e effe

ct of

each

sym

ptom

on

the d

ay(s

) you

hav

e it.

0 . . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. . . .

. 10No

inter

feren

ce w

ith lif

eMo

st int

erfere

nce w

ith lif

e

10. R

ecord

sig

nif

icant

life

eve

nts

, both

posi

tive

and n

egati

ve

Reco

rd si

gnifi

cant

pos

itive

and

nega

tive e

vent

s eac

h da

y, su

ch as

anar

gum

ent w

ith a

love

d on

e, ill

ness

in th

e fam

ily, a

pro

mot

ion

at wo

rk o

ran

ythin

g els

e tha

t affe

cts yo

u. R

ate th

e im

pact

of ea

ch ev

ent o

n th

e day

(s)

the e

vent

affec

ts yo

u.

-10 . .

. . . .

. . . .

. . . .

. . . .

. . . .

. 0 . . . .

. . . .

. . . .

. . . .

. . . .

. . . +

10Mo

st ne

gativ

e imp

act

No im

pact

Most

posit

ive im

pact

Pers

onal

Cale

ndar

A m

onth

ly di

ary

We’

ve b

een

th

ere.

We

can

hel

p.

The Depression and Bipolar Support Alliance (DBSA)is the leading patient-directed national organization focusing on the m

ost prevalent mental illnesses. The

organization fosters an environment of understanding about the im

pact andm

anagement of these life-threatening illnesses by providing up-to-date, scientifically-

based tools and information written in language the general public can understand.

DBSA supports research to promote m

ore timely diagnosis, develop m

ore effectiveand tolerable treatm

ents and discover a cure. The organization works to ensure thatpeople living with m

ood disorders are treated equitably.Assisted by a Scientific Advisory Board com

prised of the leading researchers andclinicians in the field of m

ood disorders, DBSA has more than 1,000 peer-run

support groups across the country. Over four million people request and receive

information and assistance each year. DBSA's m

ission is to improve the lives of

people living with mood disorders.

We’ve b

een th

ere.W

e can h

elp.

Using

this

calen

dar t

o trac

k you

r moo

dTh

is ca

lenda

r help

s yo

u m

onito

r you

r moo

d on

a d

aily

basis

. It c

an h

elpyo

u an

d yo

ur h

ealth

car

e pr

ofes

siona

l rev

iew y

our s

ympt

oms

and

treatm

ent.

At th

e en

d of

eac

h da

y, tak

e a

few m

omen

ts to

thin

k ab

out y

our d

ay, w

hat

you

expe

rienc

ed, h

ow y

ou fe

lt, h

ow y

ou a

cted,

etc.

The

n sim

ply

follo

w th

ese

steps

for r

ecor

ding

the

info

rmati

on.

1.

Me

dic

ati

on

s/H

erb

al

sup

ple

me

nts

List

all th

e m

edica

tions

and

sup

plem

ents

you

take

in th

e sp

aces

prov

ided

, inc

ludi

ng th

e da

ily d

osag

es a

nd n

umbe

r of p

ills

that

shou

ldbe

take

n ea

ch d

ay. A

t the

end

of e

ach

day,

write

the

exac

t num

ber o

ftab

lets

or c

apsu

les o

f eac

h m

edica

tion

that

you

actu

ally

took

in th

eap

prop

riate

day’s

spa

ce.

2.

Alc

ohol or

dru

g u

se

Put a

che

ck m

ark

in th

e ap

prop

riate

spac

e if

you

dran

k or

use

d dr

ugs.

3.

Hours

of

sleep

Estim

ate th

e nu

mbe

r of h

ours

of s

leep

you

had

the

prev

ious

nig

ht.

4.

Rate

the s

eve

rity

of

your

mood e

pis

odes

Indi

cate

how

your

moo

d ha

s aff

ected

you

r abi

lity

to fu

nctio

n at

hom

e, wo

rk, o

r sch

ool b

y pu

tting

an

✘in

the

appr

opria

te sp

ace.

Use t

he fo

llowi

ng sc

ale as

refer

ence

:M

AN

IASe

vere

Fami

ly an

d frie

nds w

ant m

e in t

he ho

spita

lHi

gh m

oder

ateMu

ch fe

edba

ck th

at be

havio

r is st

range

or bi

zarre

Low

mod

erate

Some

feed

back

that

beha

vior is

diffic

ult or

odd

Mild

Very

energ

etic;

functi

oning

may

be en

hanc

ed or

sligh

tly di

sorga

nized

STA

BLE

MO

OD

DEP

RES

SIO

NM

ildLo

w mo

od; e

ssen

tially

no im

pairm

ent in

usua

l func

tionin

gLo

w m

oder

ateSo

me ex

tra ef

fort n

eede

d in u

sual

roles

High

mod

erate

Much

extra

effor

t nee

ded;

marke

d diffi

culty

in us

ual ro

utine

sSe

vere

Large

ly un

able

to fun

ction

beca

use o

f dep

ressio

n