Impulse Tracking Form
Record and reflect on impulses to identify patterns and develop healthier responses.
Date and Time of Impulse
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
What type of impulse did you experience?
*
Please Select
Eating/Craving Food
Shopping/Spending
Social Media/Screen Use
Anger/Outburst
Procrastination/Avoidance
Other
What triggered this impulse? (Describe the situation, people, or feelings involved)
*
What was your emotional state before the impulse?
*
Please Select
Calm
Anxious
Bored
Stressed
Sad
Excited
Other
How did you respond to the impulse?
*
What was the outcome of your response?
*
Please Select
Gave in to the impulse
Resisted the impulse
Partially gave in
Additional notes or reflections (optional)
Submit Entry
Should be Empty: