Table I. Adapted SRM-5.
| ID: | Adapted SRM-5 | Initials: | |||||||||||
| Directions: | |||||||||||||
| • Record the ideal (or target) time you would like to do these daily activities | |||||||||||||
| • Record the time you actually did the activity each day | |||||||||||||
| • Record the people involved in the activity: 0= Alone; 1= Others present; 2= Others actively involved; 3= Other very stimulating | |||||||||||||
| Day and Date: | |||||||||||||
| Activity | Target time | Time | People | Time | People | Time | People | Time | People | Time | People | Time | People |
| Out of bed | |||||||||||||
| First contact with other person | |||||||||||||
| Start work/school/Volunteer/family care | |||||||||||||
| Dinner | |||||||||||||
| To bed | |||||||||||||
| Rate ENERGY LEVEL each day from -5 to +5 -5= very slowed, fatigued I + 5 = very energetic, active |