Sample Diary Form Items

TIME ___:___

LOCATION

• ___ My Work Area
• ___ Other Work Area
• ___ Work Break
• ___ Commuting
• ___ Home / Yard
• ___ Other's Home
• ___ Miscellaneous

POSITION

• ___ Standing
• ___ Sitting
• ___ Reclining

THINGS ARE

• ___ Very Busy
• ___ A Little Busy
• ___ Not Busy

I'M INTERACTING WITH

• ___ Patient(s)
• ___ Patient's Family
• ___ MD(s)
• ___ Coworker(s)
• ___ Subordinate(s)
• ___ Supervisor
• ___ Husband / Wife
• ___ My Child(ren)
• ___ Other Family
• ___ Friend(s)
• ___ Pet(s)
• ___ Other(s)__________________
• ___ How Many?

CURRENT ACTIVITY (Check all that apply)

PHYSICAL

• ___ Walking
• ___ Driving / Riding
• ___ Light Exertion
• ___ Heavy Exertion

MENTAL / SOCIAL

• ___Clerical / Routine Tasks
• ___ Reading / Writing / Thinking
• ___ Waiting
• ___ Arguing / Conflict
• ___ Laughing
• ___ Meeting
• ___ Talking / Telephone

EAT / DRINK / SMOKE

• ___ Cigarette
• ___ Coffee (caffeinated)
• ___ Alcoholic Drink
• ___ Other Food / Drink

OTHER

• ___ Bathroom / Dressing
• ___ Chores
• ___ Cooking
• ___ Dozing / Napping
• ___ Recreation
• ___ Shopping
• ___ Television

FEELINGS (how much do you feel?)

On a Scale of 1-4 (1=not at all / 2=a little / 3=moderately / 4=a lot)

• ___ Angry / Hostile
• ___ Frustrated / Annoyed
• ___ Happy / Joyful
• ___ Tired
• ___ Unhappy / Depressed
• ___ Overwhelmed