Table 1. Daily record of severity of problems.

Date (month/day/year):
Note if spotting or menses with S or M:
1. Felt depressed, sad, “down,” or “blue”; or felt hopeless; or felt worthless or guilty
2. Felt anxious, tense, “keyed up,” or on edge
3. Had mood swings (i.e., suddenly feeling sad or tearful) or was sensitive to rejection or feelings were easily hurt
4. Felt angry or irritable
5. Had less interest in usual activities (work, school, friends, hobbies)
6. Had difficulty concentrating
7. Felt lethargic, tired, or fatigued; or had a lack of energy
8. Had increased appetite or overate; or had cravings for specific foods
9. Slept more, took naps, found it hard to get up when intended; or had trouble getting to sleep or staying asleep
10. Felt overwhelmed or unable to cope or felt out of control
11. Had breast tenderness, breast swelling, bloated sensation, weight gain, headache, joint or muscle pain, or other physical symptoms
12. At work, school, home, or in daily routine, at least one of the problems noted above caused reduction of productivity or inefficiency
13. At least one of the problems noted above caused avoidance of or less participation in hobbies or social activities
14. At least one of the problems noted above interfered with relationships with others

Note the degree to which you experience each of the problems listed below. Complete this assessment in the evening only prior to bedtime. Enter the number that corresponds to the severity as noted here: 1 = not at all, 4 = moderate, 2 = minimal, 5 = severe, 3 = mild, 6 = extreme.