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Instructions for filling out the Mood Disorder/Complex PTSD Charting Tool:
The form is located on the "symptoms" worksheet.
Only certain parts of this form are filled out - the remainder of the form will automatically calculate based on information input in
For each day in the month you will be providing information related to sleep, weight, core moods, medications, ability to work an
Filling out the form:
1. Sleep Hours - Input the number of hour sleep from the previous evening. Include any time that was spent napping througho
Sleep should be input in decimal format and rounded up to the half-hour - example: 8 or 8.5
2. Weight: Input your weight for the day. It is best to weigh yourself at the same time each day, however, this is not required.
3. Depression: Select a number based on your self-evaluated level of depression for this date using the following scale:
Depression Scale
0 baseline Normal; feel good; productive; good concentration; taking one day at a time; handling life's problems as they arise; can plan a
-1 mild Below normal; mild depression; lack of energy; feel slowed down; anxiety; decreased motivation; "going through the motions."
-2 low moderate Moderate depression; loss of energy; disinterest in others; weight, sleep, and/or appetite disturbances; function only with effor
-3 high moderate Unable to work; loss of energy; isolating; weight, sleep, and/or appetite disturbances; function only with extreme effort; much a
-4 severe Depressed; feeling abandoned; serious sleep disturbance; very withdrawn; suicidal ideations not acted on; obsessing thought
4. Anxiety: Select a number based on your self-evaluated level of anxiety for this date using the following scale:
Anxiety Scale
0 baseline
1 mild
Use the Anxiety checklist on the Anxiety Check worksheet if you need help determining
2 low moderate
your level of anxiety each day
3 high moderate
4 severe
4. Mania: Select a number based on your self-evaluated level of mani for this date using the following scale:
Mania Scale
0 baseline Normal; feel good; productive; good concentration; taking one day at a time; handling life's problems as they arise; can plan a
1 mild Feel positive; confident; creative; high-energy; perceptive; awareness of hyperactivity; may want to spend money and travel.
2 low moderate Overactive; overtalkative; many ideas for new projects; scattered creativity; socially inappropriate; sleeping 4-6 hours; feel won
3 high moderate Feel eveything is working perfectly; elated; sleeping very little; hostile when "crossed"; racing thoughts; inappropriate spending
4 severe Highly Elated; can't rate self; delusions of gradeur; beligerent; distortion of time; disdainful; unable to control emotions and tho
5 mixed presents symptoms of both depression and mania. For example, may have all the frantic energy of mania, but may also be str
5. Medications: Input your medication and daily amount at the top of each medication column. Each day enter the amount of m
If medication was missed or skipped for the day, input 0.
6. Able to Work/Unable to Work: Select "A" if you were able to work on this day, Otherwise select "U"
7. Daily Symptoms: For each symptom, select "1" or input "1" if you experienced the symptom on that day of the month. Other
8. Notes: Fill out the notes log for any information that you would like to track.
After you have filled out all information on the form, the charts will automatically update.
If you can think of any improvements to the form, I would love to hear from you. Email: lisa@timesnaps.com
ulate based on information input into the form.
ods, medications, ability to work and experienced symptom for that day.
e that was spent napping throughout the day.
ay, however, this is not required.
te using the following scale:
handling life's problems as they arise; can plan ahead and carry through.
creased motivation; "going through the motions."
or appetite disturbances; function only with effort; much anxiety; feeling life is not worthwhile; feeling isolated; ruminating thoughts.
bances; function only with extreme effort; much anxiety; feeling life is not worthwhile; feeling isolated; ruminating thoughts.
uicidal ideations not acted on; obsessing thoughts.
he following scale:
sheet if you need help determining
h day
following scale:
handling life's problems as they arise; can plan ahead and carry through.
ractivity; may want to spend money and travel.
ocially inappropriate; sleeping 4-6 hours; feel wonderful; mildly obtrusive. Check medication(s).
rossed"; racing thoughts; inappropriate spending.
e; disdainful; unable to control emotions and thoughts.
l the frantic energy of mania, but may also be struggling with the black thoughts of depression
n. Each day enter the amount of medication that was taken that day.
m on that day of the month. Otherwise leave the symptoms field blank.
timesnaps.com
Rate your Anxiety Level
Rate each item based on a 5 point scale: 0 (blank) to 4 (blank=not present, 4=severe)
Symptoms Day 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
Anxious Mood-Worrying, Anticipating the Worst
Tension - Startles, Cries Easily, Restless, Trembling
Fears - Fear of the dark, Fear of strangers, Fear of being alone, Fear of Animals, Other Fears
Insomnia - Difficulty Falling Asleep, Nightmares, Broken Sleep
Intellectual - Poor Concentration, Memory Impairment
Depressed Mood
Somatic Complaints - Muscular Aches or Pains
Somatic Sensory - Ringing of the Ears, Blurred Vision
Cardiovascular - Chest Pains, Tightening of Chest, Palpitations, Sensation of Feeling Faint
Respiratory - Chest Pressure, Choking Sensation, Short Breath
GastroIntestinal - Nausea/Vomiting, Diarrhea, Constipation, Weight Loss, Abdominal Fullness
Genitourinary - Urinary Frequency/Urgency, Impotence, Pelvic Pain, Cramps, Painful Menstruation
Autonomic Symptoms - Dry Mouth, Flushing, Pallor, Sweating
Behavioral - Fidgeting, Tremors, Trembling/Shaking, Pacing
Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base Base
Depression Scale Anxiety Scale Mania Scale Work Scale
0 baseline 0 baseline 0 baseline A Able to Work
-1 mild 1 mild 1 mild U Unable to Work
-2 low moderate 2 low moderate 2 low moderate
-3 high moderate 3 high moderate 3 high moderate
-4 severe 4 severe 4 severe
5 mixed
GAF Scale
91-100
81-90
71-80
61-70
51-60
41-50
31-40
21-30
11-20
0-10
Symptoms Scale
Able to Work Blank No Symptom
Unable to Work 1 Symptom Present
9
8
7
6
5
4
3
2
1
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
Date
Sleep Hours
Weight
Scale Keys:
Depression Level
Anxiety Level
### ### ## ##
Mania Level (if BiPolar)
-1 mild
-4 severe
0 baseline
Self GAF (0-100) Use Chart Below
-2 low moderate
-3 high moderate
Depression Scale
Med 1: Lithium 1200MG
Med 2: Wellbutrin 400MG
Med 3: Trazodone 100MG
Med 4: Oxycodone 5MG x3 as needed
1 mild
Med 5:
4 severe
(A)ble to Work' (U)nable to Work
0 baseline
Anxiety Scale
9
8
7
6
5
4
3
2
1
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
2 low moderate
3 high moderate
No Shower/Bath
No Change of Clothes
Poor Appetite/Overeating/Undereating
Missed Medications
No Oral Hygiene
1 mild
Drug/Alcohol Use or Abuse
5 mixed
4 severe
Self-Injury or Thought of Self-Harm
0 baseline
Self-Care
Mania Scale
Not Sleeping/Difficulty Sleeping
2 low moderate
Missed Medical Appointments
3 high moderate
Financial Irresponsibility
Aches/Pain
0 0 0 0 0 0 0 0 0 0 0
9
8
7
6
5
4
3
2
1
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
Persistent Sadness
Suicidal/Homicidal Thoughts
Explosive Anger
Work Scale
Medications:
Inhibited Anger
A Able to Work
Extreme Emotional Reactions
U Unable to Work
Emotional Numbing
Irritability
Anxiety/Panic/Feel out of control
Crying
Agitation
Emotional Regulation
Exaggerated Startle
Hypervigilance
0 0 0 0 0 0 0 0 0 0 0 0
Difficulty Concentrating/Confusion
Symptoms Scale
Raging at Others
0 0
1 = Symptom Present
9
8
7
6
5
4
3
2
1
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
For each day, Input amount of each medication taken
(Trying to) Forget Traumatic Events
0
Blank = No Symptom Present
Reliving Traumatic Events
0
Detached from Mental Processes or Body
0
Flashbacks
0
List Medications and Daily Prescribed amounts in Medication Field
Nightmares
0
Zoning Out/Dissociative
0
Conciousness
Amnesia/Forgetfulness
0
Unable to Make Decisions
Loss of Interest in Activities/other
Intrusive Memories
0 0 0
9
8
7
6
5
4
3
2
1
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
Helplessness
Shame
Guilt
Stigma
Completely Different from Others
Believe self to be bad or broken
Self-Perception
Worthlessness
0 0 0 0 0 0 0
9
8
7
6
5
4
3
2
1
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
Attribute total or "super" power to other
Preoccupied with relationship to perp
Preoccupation for Revenge
Preoccupation with what others think
Accepting distorted beliefs of others
0 0 0 0 0
Other Perception
9
8
7
6
5
4
3
2
1
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
Isolation
Distrust
Search for Rescuer
Emotional detachment
Avoiding Physical/Emotional Contact
Demeaning/Emotionally Attacking Others
Frantic Attempts to Escape Others
Arguments/Fights/Violence
Relations to Others
Avoidance of Responsibilities
Emotional Abusive Behavior
0 0 0 0 0 0 0 0 0 0
9
8
7
6
5
4
3
2
1
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
Loss of sustaining faith
Hopelessness
Despair
Foreshortened Future
Will not have what other's have
Life is too hard
0 0 0 0 0 0
Systems of Meaning
9
8
7
6
5
4
3
2
1
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
Inappropriate Elation
Increased Irritability
Grandiosity/"Great" Plans/Schemes
Inappropriate Social Behavior
Hallucinations/Delusions
Increased Speed/Volume of Speech
Impulsivity
Spending Money
Disconnected/Racing Thoughts
Mania Symptoms
Increased Sexual Desire/Promiscuity
Poor Judgement
0 0 0 0 0 0 0 0 0 0 0
Marked Increase Energy and Activity
0
Monthly Self-Evaluative General Assessment of Functioning
Scale 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
Symptoms: No Symptoms.
Level of Function: Superior functioning in a wide range of activities, problems 91-100
never seem to get out of hand. Is sought out by others because of his or her
0
many positive qualities
Symptoms: Absent or minimal symptoms (e.g., mild anxiety before an exam),
Generally satisfied with life.No more than everyday problems or concerns (e.g.,
an occasional argument with family members). 81-90 0
Level of Function: Good functioning in all areas, interested and involved in a
wide range of activities, socially effective,
Symptoms: If symptoms are present, they are transient and expectable
reactions to psychosocial stressors (e.g., difficulty concentrating after family
argument
Level of Function: No more than slight impairment in social, occupational, or
71-80 0
school functioning (e.g., temporarily falling behind in school work).
Symptoms: Some mild symptoms (e.g., depressed mood and mild insomnia)
Level of Function: Some difficulty in social, occupational or school functioning
(e.g., occasional truancy, or theft within the household), but generally
61-70 0
functioning pretty well, has some meaningful interpersonal relationships
Symptoms: Moderate symptoms (e.g., flat affect and circumstantial speech,
occasional panic attacks)
Level of Function: Moderate difficulty in social, occupational, or school
51-60 0
functioning (e.g., few friends, conflicts with co-workers).
Symptoms: Serious symptoms (e.g., suicidal ideation, severe obsessional
rituals, frequent shoplifting).
Level of Function: Any serious impairment in social, occupational, or school
41-50 0
functioning (e.g., no friends, unable to keep a job).
Symptoms: Some impairment in reality testing or communication (e.g., speech
is at time illogical, obscure or irrelevant)
Level of Function: Major impairment in several areas, such as work or school,
family relations, judgment, thinking, or mood (e.g., depressed man avoids
31-40 0
friend, neglects family, and is unable to work; child frequently beats up younger
children, is defiant at home and is failing in school).
Symptoms: Behavior is considerably influenced by delusions or hallucinations
Or serious impairment in communication or judgment (e.g., sometimes
incoherent, acts grossly inappropriately, suicidal preoccupation) 21-30 0
Level of Function: Inability to function in almost all areas (e.g., stays in bed
all day, no job, home or friends)
Symptoms: Some danger of hurting self or others (e.g., suicide attempts
without clear expectation of death; frequently violent; manic excitement) Or
Gross impairment in communication (e.g., largely incoherent or mute) 11-20 0
Level of Function: Occasionally fails to maintain minimal personal hygiene
(e.g., smears feces)
Symptoms: Persistent danger of severely hurting self or others (e.g., recurrent
violence) Or serious suicidal act with clear expectation of death. 0-10 0
Level of Function: Persistent inability to maintain minimal personal hygiene
Notes for the Month
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
0
1
2
3
4
6
7
8
9
5
11
12
13
14
15
16
18
19
20
21
23
24
25
26
27
28
30
31
10
17
22
29
No Shower/Bath
No Change of Clothes
Poor Appetite/Overeating/Undereating
Missed Medications
No Oral Hygiene
Drug/Alcohol Use or Abuse
Self-Injury or Thought of Self-Harm
Self-Care
Not Sleeping/Difficulty Sleeping
Missed Medical Appointments
Financial Irresponsibility
Aches/Pain
Persistent Sadness
Suicidal/Homicidal Thoughts
Explosive Anger
Inhibited Anger
Extreme Emotional Reactions
Emotional Numbing
Irritability
Anxiety/Panic/Feel out of control
Crying
Agitation
Emotional Regulation
Exaggerated Startle
Hypervigilance
Difficulty Concentrating/Confusion
Raging at Others
(Trying to) Forget Traumatic Events
Reliving Traumatic Events
Detached from Mental Processes or Body
Flashbacks
Nightmares
Zoning Out/Dissociative
Amnesia/Forgetfulness
Conciousness
Unable to Make Decisions
Loss of Interest in Activities/other
Intrusive Memories
Helplessness
Shame
Guilt
Stigma
Completely Different from Others
Believe self to be bad or broken
Self-Perception
Worthlessness
Attribute total or "super" power to other
Preoccupied with relationship to perp
Preoccupation for Revenge
Monthly Symptoms Monitoring Chart
Preoccupation with what others think
Accepting distorted beliefs of others
Other Perception
Isolation
Distrust
Search for Rescuer
Emotional detachment
Avoiding Physical/Emotional Contact
Demeaning/Emotionally Attacking Others
Frantic Attempts to Escape Others
Arguments/Fights/Violence
Relations to Others
Avoidance of Responsibilities
Emotional Abusive Behavior
Loss of sustaining faith
Hopelessness
Despair
Foreshortened Future
Will not have what other's have
Life is too hard
Systems of Meaning
Inappropriate Elation
Increased Irritability
Grandiosity/"Great" Plans/Schemes
Inappropriate Social Behavior
Hallucinations/Delusions
Increased Speed/Volume of Speech
Impulsivity
Spending Money
Mania Symptoms
Disconnected/Racing Thoughts
Increased Sexual Desire/Promiscuity
Poor Judgement
Marked Increase Energy and Activity
Monthly Number of PTSD Symptomatic Days
Depression/Anxiety/Mania Scale Days with Symptoms Total Symptoms
31
30
Depression/Anxiety/Mania
29
5 Scale Range: 28
Depression: Anxiety 27
4
26
0 = Baseline 0 = Baseline
3 25
-1 = Mild 1 = Mild 24
2 23
-2 = Low Moderate 2 = Low Moderate
1 22
-3 = High Moderate 3 = High Moderate 21
0 -4 = Severe 4 = Severe 20
19
-1 18
-2 Mania 17
0 = Baseline 16
-3 15
1 = Mild (Hypomania) 14
-4 2 = Low Moderate 13
-5 12
3 = High Moderate
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 11
4 = Severe 10
Depression 9
5 = Mixed Mania/Depression
8
Anxiety 7
Mania 6
5
4
Day of Month 3
2
1
0
0
0
0
0
0
0
0
0
Arousal
Re-experiencing
Avoidance
Emotional Numbing
Monthly Sleep Monitoring Self-Evaluative GAF
31
30
29
28
27
GENERAL PTSD SYMPTOMS
26
25
24
23
Average Weight: #DIV/0!
22
Average Sleep: #DIV/0!
21
20
Number of Days Able to Work: 0
Number of Days in Month
19
Number of Days Unable to Work: 0
18
17
Number of Days Financial Mishaps: 0
16
0 15
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
14
Sleep Hours
13
12
11
Monthly Weight Monitoring 10
110 9
100 8
90 7
80 6
70 5
60 4
50 3
40 2
30 1
20 0
91-
81-90 71-80 61-70 51-60 41-50 31-40 21-30 11-20 0-10
10 100
0 Days 0 0 0 0 0 0 0 0 0 0
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
GAF SCALE
GENERAL PTSD SYMPTOMS
Emotional Numbing
Re-experiencing
Avoidance
Arousal
Date
0 0 0 0
1 0 0 0 0
2 0 0 0 0
3 0 0 0 0
4 0 0 0 0
5 0 0 0 0
6 0 0 0 0
7 0 0 0 0
8 0 0 0 0
9 0 0 0 0
10 0 0 0 0
11 0 0 0 0
12 0 0 0 0
13 0 0 0 0
14 0 0 0 0
15 0 0 0 0
16 0 0 0 0
17 0 0 0 0
18 0 0 0 0
19 0 0 0 0
20 0 0 0 0
21 0 0 0 0
22 0 0 0 0
23 0 0 0 0
24 0 0 0 0
25 0 0 0 0
26 0 0 0 0
27 0 0 0 0
28 0 0 0 0
29 0 0 0 0
30 0 0 0 0
31 0 0 0 0
0 0 0 0
