Name: _______________________________
Primary Therapist: _____________________
Date: _____________
Nutritionist: ________________________
Daily Assessment Sheet
Intensity of Urges
Urges
Restricting
Purge
Binge
Laxative Use
Micro-biting
Micro-tearing
Exercise
Body Checking
Y/N
If yes, Rate 1-5
Engaged in Behavior for the past 24 hours?
Do you have any urges to engage in self-harm? Y or N (Circle one) If yes, rate 1-5 _________________
If yes, explain _________________________________________________________________________
_____________________________________________________________________________________
Have you engaged in self-harm in the last 24 hours? _________________________________________
If yes, what did you use to engage in self-harm with?________________________________________
Do you have any suicidal ideations? Y or N (Circle one) Do you have a plan or intent? Y or N (Circle one)
Are you taking your medications? Y or N (Circle one) How many hours of sleep last night? ____________
Current Symptoms Checklist: (check for any symptoms present)
( ) Depressed Mood
( ) Racing Thoughts
( ) Excessive Worry
( ) Unable to Enjoy activities
( ) Impulsivity
( ) Anxiety Attacks
( ) Sleep pattern disturbance
( ) Increased Risky Behavior
( ) Avoidance
( ) Loss of Interest
( ) Decreased need for sleep
( ) Hallucinations
( ) Concentration/forgetfulness
( ) Excessive energy
( ) Suspiciousness
( ) Change in appetite
( ) Increased Irritability
( ) Crying spells
( ) Fatigue
( ) Nausea
( ) Bloating
( ) Panic Attacks
( ) ___________________
( ) ___________________
What Zone are you in today?
What emotion are you identifying with today?
Is there anything you would like your treatment team to know?