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1=sad, tired, anxious, tense, irritable, withdrawn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: _________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

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

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

What difficulties did I have sticking with my treatment plan?

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

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________ 

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

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

I experienced the following side effects this week:

_ Nausea

_ Sexual difficulties

_ Constipation

_ Dizziness

_ Weight gain/loss (___ lbs.)

_ Shortness of breath

_ Shaking

_ Dry mouth

_ Other:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

In what ways am I feeling better than last week?

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Do I think I could be doing better?

_ Yes

_ No

If yes, in what ways?

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Questions to ask my doctor:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Goals for my next appointment:  

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________