Mood Tracking Form
Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Male
Female
Prefer not to say
1) How do you feel right now?
Bad
1
2
3
4
Good
5
1 is Bad, 5 is Good
2) Which color make you feel more positive right now?
Red
Green
Yellow
Purple
White
Black
Blue
Other
3) Which color make you feel more negative right now?
Red
Green
Yellow
Purple
White
Black
Blue
Other
4) Are there any colors that make you feel better when you're sick?
Yes
No
How Often You Experience the Moods
5) Rate your Happiness Level
Never
1
2
3
4
Constantly
5
1 is Never, 5 is Constantly
6) Rate your Sadness Level
Never
1
2
3
4
Constantly
5
1 is Never, 5 is Constantly
7) Rate your Rage Level
Never
1
2
3
4
Constantly
5
1 is Never, 5 is Constantly
8) Rate your Boredom Level
Never
1
2
3
4
Constantly
5
1 is Never, 5 is Constantly
9) What makes you happy? Please list them all.
10) What causes you to be sad? Please list them all.
11) What annoys you? Please list them all.
Do you have any further thoughts?
Submit
Should be Empty: