INSTRUCTIONS
1. Please rate your mood at the end of each day by placing an ‘X’ in the appropriate box. If you have experienced both a ‘high’ and a ‘low’
mood on any given day, please rate both by putting an ‘X’ at each level
2. Please write the name of the medications and doses you are taking
3. Next to each medication, please indicate the period of time you took the medication at the same dose by drawing an arrow through the
relevant dates. If your dose changes during the course of the charting period, please write the new dose in the relevant box and continue
the line.
4. Please also include notes on sleep patterns, any triggers or external events that may impact you and cause a mood change.
This document may be freely downloaded and distributed on condition no change is made to the content. The information in this document is not intended as a substitute for professional
medical advice, diagnosis or treatment. Not to be used for commercial purposes and not to be hosted electronically outside of the Black Dog Institute website.