Name:
Today I am
years old plus
days
(day month year to appear here, in parenthesis)
Today, I awoke from
0
1
2
3
4
5
6
7
8
9
10+
hours of sleep.
Today, I drank this many cups of coffee or tea:
0
1
2
3
4
5
6
7
8
9
10+
Today, I smoked this many cigarettes:
0
1-5
6-10
11-15
16-20
20+
Today I
ate well
did not eat well
Today I had the following number of bowel movements:
n/a
1
2
3
4
5
Today I
n/a
did
did not
have sex.
Today I
n/a
did
did not
masturbate.
Today I
n/a
did
did not
have at least one orgasm.
I am on the following day of my menstrual cycle today (for menstruating women only):
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
32
33
34
35
Today, I had an interesting conversation with
about
The most exciting thing I did today was
The most boring thing I did today was
On a scale of 1-10, my level of happiness today was
1
2
3
4
5
6
7
8
9
10
On a scale of 1-10, my level of anxiety today was
1
2
3
4
5
6
7
8
9
10
I
did
did not
fill out this form today, instead of making art
Updated January 2009 | Acknowledgements | Copyright ©1998-2009 Risa Horowitz