How is My Treatment Plan Working?

This worksheet can help you check your progress and find out which issues need to be discussed at future appointments.

You may want to make copies and use one each week.

WEEK OF _________________________________


NEXT APPOINTMENT _________________________________


On a scale of one to ten, how do you feel? (circle the number)

1    2    3    4    5    6    7    8    9    10

1=sad, tired, anxious, tense, irritable, withdrawn
10=happy, rested, relaxed, energized, involved in life

Check any words that describe how you felt this week.

_ Trouble concentrating

_ Sad/Crying

_ Joyful/Pleased

_ Overeating/Not eating

_ Slept too much/Trouble sleeping

_ Irritable/Angry/Worried/Anxious

_ Calm

_ Don’t care/Pessimistic

_ Lazy/No energy

_ Interested/Involved in life

_ Aches and pains

_ Guilty/Hopeless/Worthless/Overwhelmed

_ Difficult to concentrate or make decisions

_ Wanted to be alone

_ Happy/Content

_ Thoughts of death or suicide

_ Working well/Clear thinking

_ Alcohol/Substance use

_ Active

_ Other: _________________________________

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Have my family, co-workers or friends said anything about my mood? If so, what?

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What difficulties did I have sticking with my treatment plan?

(medication, talk therapy, support groups, etc.)

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Did my medication make me feel bad in any way? How? 

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I experienced the following side effects this week:

_ Nausea

_ Sexual difficulties

_ Constipation

_ Dizziness

_ Weight gain/loss (___ lbs.)

_ Shortness of breath

_ Shaking

_ Dry mouth

_ Other:

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In what ways am I feeling better than last week?

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Do I think I could be doing better?

_ Yes

_ No

If yes, in what ways?

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Questions to ask my doctor:

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Goals for my next appointment:  

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