Mood Chart Template
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1Mood Chart
Adapted from Sachs, G (1996): J. Clin. Psychopharm. 16:2(suppl 1) p47S
Name _____________________________________
id # _________________________
Clinician ___________________________
Mo/Yr ____________
Medication
Date
Mood
Sleep
Other symptoms
Comments
(enter number of pills taken each day)
med 1
med 2
med 3
med 4
med 5
med 6
two check marks:
enter 0-3
check one:
for instance:
for instance:
worst and best for each day
activated or
0=none
depressed
nl
problems w/
euphoric
1=mild
cognition or
significant events that might affect
(circle for
2=moderate
mood — interactions, successes,
memory,
menses)
3=severe
hallucinations,
disappointments, anniversaries, illness,
paranoid ideas,
losses, etc.
etc.
anx.
irrit.
+++
++
+
+
++
+++
mg
mg
mg
mg
mg
mg
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
weight =
Adapted by Peter M. Brigham, MD 1997-8
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